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MEDICAL AND SURGICAL 

DISEASES 



OF THE 



KIDNEYS AND URETERS 



/ 



BY 



BUKK G. CARLETON, M.D. 

GENITO- URINARY SURGEON AND SPECIALIST TO THE METROPOLITAN HOSPITAL 
BLACKWELLS ISLAND, DEPARTMENT OF PUBLIC CHARITIES OF NEW YORK 
CITY AND THE METROPOLITAN HOSPITAL POLYCLINIC. — LATE VISITING 
PHYSICIAN TO THE WARDS ISLAND HOSPITAL. — LATE PATHOLOGIST 
AND INTERNE OF THE WARD'S ISLAND HOSPITAL. — LATE ADJUNCT 
PROFESSOR AND DEMONSTRATOR OF ANATOMY OF THE NEW YORK 
HOMOEOPATHIC MEDICAL COLLEGE. — MEMBER OF THE AMER- 
ICAN INSTITUTE OF HOMOEOPATHY. — THE HOMCEOPATHIC 
MEDICAL SOCIETY OF THE STATE OF NEW YORK. — THE 
HOMCEOPATHIC MEDICAL SOCIETY OF THE COUNTY 
OF NEW YORK. — ACADEMY OF PATHOLOGICAL 
SCIENCE. — HOMCEOPATHIC MATERIA MEDICA 
SOCIETY OF NEW YORK. — NEW YORK 
P.EDOLOGICAL SOCIETY, ETC, ETC, ETC 



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Copyright, 189^, 

BOERICKE, R UNION & ERKFSTY. 



TO THE 

COMMISSIONERS OF PUBLIC CHARITIES 

AND THE 

MEMBERS OF THE MEDICAL BOARD 

OF THE 

METROPOLITAN HOSPITAL, BLACKWELLS ISLAND, 
NEW YORK CITY 

IN APPRECIATION OF THE CONSIDERATION AND MANY 

ADVANTAGES ENJOYED BY THE AUTHOR DURING- 

HIS TWENTY-ONE YEARS' CONNECTION 

AYITH THE HOSPITAL, 

THIS LITTLE VOLUME 

IS 

RESPECTFULLY DEDICATED. 



PREFACE. 



1\ /T ANY professional friends have requested me 
-^*-*- to prepare and publish a practical working 
companion volume to my Manual on Genito-Urinary 
and Venereal Diseases, so as to complete the subject 
of the Uropoietic diseases. In accordance with their 
request this monograph on the Medical and Surgical 
Diseases of the Kidneys and Ureters has been written 
and is now presented to the medical profession. 

It has been the aim of the author to incorporate 
all new facts from reliable sources together with his 
personal experience obtained at the Metropolitan 
Hospital and in private practice. Theories have been 
omitted and established facts only presented. 

The treatment of each disease, medical and surgical, 
is fully considered. 

As only brief drug indications have been given in 
the treatment of the different diseases described, 
Chapter XL. must therefore be consulted when 
more complete symptomatic and clinical indications 
are required. 



The author is greatly indebted to Dr. E. D. Klots, 
Curator of the Metropolitan Hospital, for valuable 
assistance in the preparation of the sections on path- 
ological anatomy and for the photomicro graphic plates 
demonstrating pathological changes, and to Dr. E. 
du Jardin for his assistance in seeing the manuscript 

through the press. 

Bukk G. Carleton. 
75 West 50th Street, 
New York City. 



CONTENTS. 



CHAPTER I. 

Malformations of the Kidneys and Ureters 17 

CHAPTER II. 
Nephroptosis. — Etiology. — Clinical History. — Diagnosis. — Treatment. . 20 

CHAPTER III. 

Uraemia. — Etiology. — Headache. — Uraemic Amaurosis. — Contraction of Single 
Muscles. — Convulsions. — Delirium and Coma. — Aphasia. — Insanity. — 
Temperature. — Arterial Tension. — Dyspnoea. — Digestive Disturbances. 

— Ursemic Pruritus. — Formication. — Numbness and Pain. — Diagnosis. 

— Prognosis.^Treatment 32 

CHAPTER IV. 

Acute Congestion of the Kidney. — Etiology. — Pathological Anatomy. — Clinical 

History. — Prognosis. — Treatment. .41 

CHAPTER V. 

Chronic Congestion of the Kidneys. — Etiology. — Pathological Anatomy. — 

Clinical History. — Treatment 44 

CHAPTER VI. 

Acute Nephritis. — Etiology. — Clinical History. — Prognosis. — Treatment. . 47 

CHAPTER VII. 

Acute Degeneration of the Kidney. — Etiology. — Pathological Anatomy. — 

Clinical History. — Treatment. .48 

CHAPTER VIII. 

Chronic Degeneration of the Kidney. — Etiology. — Pathological Anatomy. — 

Clinical History. — Treatment 51 

CHAPTER IX. 

Acute Parenchymatous Nephritis. Acute Exudative Nephritis. Acute Pro- 
ductive Nephritis. Acute Bright's Disease. — Etiology. — Pathological 
Anatomy. — Clinical History. — Diagnosis. — Prognosis. — Treatment. . 53 

CHAPTER X. 
Chronic Bright's Disease 77 



CONTENTS. 

CHAPTER XL 

Chronic Parenchymatous Nephritis. Chronic Productive Nephritis with 
Exudation. Chronic Croupous or Tubal Nephritis. Chronic Glomerulo- 
Nephritis. Chronic Desquamative Nephritis. — Etiology. — Pathological 
Anatomy. — Clinical History. — Diagnosis. — Prognosis. — Treatment. . 78 

CHAPTER XII. 

Interstitial Nephritis. Renal Cirrhosis. Eenal Sclerosis. Granular Atrophy. 
Gouty Kidney. Red Granular Nephritis. Chronic Interstitial Nephritis. 
Contracted Kidney. — Etiology. — Pathological Anatomy. — Clinical His- 
tory. — Diagnosis. — Prognosis. — Treatment. 90 

CHAPTER XIII. 

Amyloid Nephritis. Lardaceous or "Waxy Kidney. Depurative Infiltration 
of the Kidney. — Etiology. — Pathological Anatomy. — Clinical History. 

— Diagnosis. — Prognosis. — Treatment. 106 

CHAPTER XIV. 

Cystic Degeneration of the Kidney. — Etiology. — Pathological Anatomy. — 

Clinical History. — Hydatid cysts, Dermoid cysts. — Treatment. . . 110 

CHAPTER XV. 

Albuminuria or Eclampsia of Pregnancy. — Etiology. — Pathological Anat- 
omy. — Clinical History. — Treatment. . 114 

CHAPTER XVI. 

Renal Tuberculosis. —Etiology. — Pathological Anatomy. — Clinical History. 

— Treatment. 122 

CHAPTER XVII. 

Renal Syphilis. Acute Syphilitic Nephritis. — Etiology. — Pathological Ana- 
tomy. — Clinical History. — Prognosis. — Treatment. — Chronic Syphilitic 
Nephritis. — Etiology. — Pathological Anatomy. — Clinical History. — 
Treatment 128 

CHAPTER XVIII. 

Renal Tumors. — Etiology. — Pathological Anatomy, Angioma, Fibroma, 
Lipoma, Lymphadenoma, Myoma, Myxolipoma, Papilloma, Adenoma, 
Carcinoma, Sarcoma. — Clinical History. — Prognosis. — Treatment. . 130 

CHAPTER XIX. 

Hydronephrosis. — Etiology. — Pathological Anatomy. — Clinical History. — 

Diagnosis. — Treatment. 136 

CHAPTER XX. 

Pyonephrosis. — Etiology. — Pathological Anatomy. — Clinical History. — 

Treatment 140 



CONTENTS. 

CHAPTER XXI. 

Pyelitis. — Etiology. Acute primary, Chronic primary, Acute secondary, 
Chronic secondary. — Pathological Anatomy. — Acute primary. Chronic 
primary, Acute secondary, Chronic secondary. — Clinical History. Acute 
primary, Chronic primary, Traumatic, Calculous, Tubercular, Acute 
secondary, Chronic secondary. — Prognosis. — Treatment. . . . 142 

CHAPTER XXII. 
Albuminuria. • 153 

CHAPTER XXIII. 

Bacteriuria. — Etiology. — Pathological Anatomy. — Clinical History. — Treat- 
ment 155 

CHAPTER XXIV. 

Chyluria. — Etiology. — Clinical History. — Treatment. .... 159 

CHAPTER XXV. 

Cystinuria. — Etiology. — Clinical History .161 

CHAPTER XXVI. 

Haematuria. — Etiology. — Clinical History. — Treatment 162 

CHAPTER XXVII. 

Oxaluria. — Etiology. — Clinical History. — Treatment 164 

CHAPTER XXVIII. 

Phosphaturia, True. — Etiology. — Clinical History. — Functional. — Etiology. 

— Clinical History. — Secondary. — Treatment 166 

CHAPTER XXIX. 

Pyuria. — Etiology. — Clinical History. — Treatment 169 

CHAPTER XXX. 

Polyuria — Persistent, transient. — Treatment 171 

CHAPTER XXXI. 

Renal Calculi.— Etiology.— Clinical History.— Treatment 173 

CHAPTER XXXII. 
Renal Colic— Etiology. — Clinical History. — Prognosis. — Treatment. . 181 

CHAPTER XXXIII. 

"Ureteritis.— Etiology.— Clinical History.— Treatment 186 



CONTENTS. 

CHAPTER XXXIV. 

Ureteral Obstruction. — Clinical History. — Treatment. .... 188 

CHAPTER XXXV. 

Ureteral Injuries and Fistulae. — Clinical History. — Treatment. . . . 192 

CHAPTER XXXVI. 

Eenal Injuries. — Clinical History. — Treatment 196 

CHAPTER XXXVII. 

Renal Fistulae. — Etiology. — Clinical History. — Reno-Cutaneous, Reno-Intes- 
tinal, Reno-Gastric and Reno-Bronchial Fistulae. — Treatment. . . 199 

CHAPTER XXXVIII. 

Suppurative Nephritis. — Etiology. — Pathological Anatomy. — Clinical His- 
tory. — Treatment. .......... 201 

CHAPTER XXXIX. 

Eenal Surgery. — Nephrorrhaphy. — Nephrotomy. — Nephrolithotomy. — Pye- 

lolithotomy. — Nephrectomy. — Lumbar, abdominal 206 

CHAPTER XL. 
Symptomatology, etc., etc 215 



MEDICAL AND SURGICAL DISEASES 
OF THE KIDNEYS AND URETERS. 



CHAPTER I. 

Malformations of the Kidneys and Ureters. 

From a surgical, if not from a medical standpoint, 
the possibilities of malformation of the kidney, the 
absence of either, or a supernumerary kidney, should 
always be considered. 

Congenital absence of one kidney is not the rare 
condition it was once thought to be. The left is 
most frequently absent, but within the past two years 
three cases of congenital absence of the right kidney 
have been reported to the N. Y. Pathological Society. 

Congenital absence of one kidney occurs in about 
one in every four thousand persons. 

Where one kidney only is present, it will be found 
enlarged, and is usually fully competent to secrete 
the urine of the body, and presents no clinical 
symptoms. When one kidney has been removed, com- 
pensatory hypertrophy, with increase in function, 
occurs in the remaining organ. 

Whenever a nephrectomy is proposed, the presence 
of both kidneys should be made sure of, not only by 
palpation and percussion of the kidney region, but 
also by cystoscopic examination, together with cath- 
eterization of the ureters. 



I 8 MALFORMATIONS OF THE KIDNEYS AND URETERS. 

Sometimes the kidneys are connected by a band of 
tissue extending between their lower ends, giving a 
horseshoe appearance, with the concavity looking 
upwards ; this is caused by dislocation and early amalga- 
mation of the embryonic points of origin. The ureters 
in this case usually pass to the bladder in front of 
the connecting baud; they may pass behind, or may 
evencross one another. Less frequently the kidneys 
are connected at their upper extremities. 

Cases have also been reported where the kidneys 
were joined together and placed in front of the great 
vessels in the lumbar region; one has been found to 
occupy the usual position, the other being placed 
over the sacro-iliac synchondrosis, or between the 
bifurcation of the aorta; there may be a double 
lobulated kidney on one side. — Dr. Gr. A. Tuttle pre- 
sented a kidney at the N. Y. Pathological Society on 
April 8, 1896, which he had removed from the hollow 
of the sacrum, its renal artery being given off close- 
to the origin of the sacro-median artery. 

Entire absence of the kidney tissue has not infre- 
quently been observed in the newly born. 

There is usually one ureter connecting each kidney 
with the corresponding side of the bladder, but cases 
are frequent where there are two or more ureters 
leaving the pelvis of the kidney, joining usually about 
one or two inches from their origin to empty by a 
common ureter into the bladder. 



MALFORMATIONS OF THE KIDNEYS AND URETERS. 19 

Double ureters are usually found in kidneys having 
two pelves. 

In the female the ureter has been known to 
open at or near the meatus urinarius giving rise to 
continuous incontinence. In these cases the ureter, 
instead of opening into the bladder, was found to 
be continued between the septum of the bladder and 
vagina opening externally, as in the case reported by 
Dr. F. H. Davenport, Trans.-Am.-Gyngecological So- 
ciety, 1890, and Dr. Baker, N. Y. Med. Journal, 
1878. Mr. Davis Colby, in the Path. Society, Lon- 
don, Vol. XXX., reports a case where the ureter 
on the left side was continued through the bladder 
and urethra, opening at the meatus urinarius. It is 
not uncommon to find the ureters greatly dilated, 
sometimes even to the calibre of the small intestines, 
caused by obstruction from below. In some cases, 
where there is marked contraction or obliteration of 
the bladder, the dilated ureter acts as a bladder or 
reservoir lor the urine. There are cases in which 
dilatation has been found in children and which must 
be considered congenital, as no obstruction w T as dis- 
covered at the autopsy. 

In regard to the vessels, it is not uncommon for 
the renal artery to enter the kidney at the pelvis 
by a number of branches or at the side, or on the 
convexitv of the organ. 



CHAPTER II. 
Nephroptosis. 

Floating and movable kidneys differ in the fact 
that the floating kidney is congenital, has a complete 
meso-nephron, and is attached to the posterior wall 
of the abdominal cavity by an extensive band of con- 
nective tissue, allowing of great latitude of mo- 
tion. The movable kidney is an acquired condition, 
due to traumatic relaxation from the abdominal pa- 
rietes, to absorption of the peri-renal adipose tissue 
which holds the kidney to the posterior abdominal 
wall, or anything that interferes with balance of 
force exerted upon the kidney from above, downward 
and backward, and from below upward and backward, 
forcing the kidney backward against the posterior 
abdominal wall by their wedge-like power. The 
movable kidney may become so loose as to allow of 
almost, if not quite, as much mobility as in the floating 
variety. As these conditions present similar symptoms, 
and may require the same treatment, they will be 
described together. 

Etiology. — The floating kidney is always congenital, 
while the movable is acquired. Increased mobility of 
the kidney is the result of various forms of traumat- 
ism. The researches of His and Cunningham give 
a clear description of the normal anchorage of the 



NEPHROPTOSIS. 2 1 

kidney, and the causes which engender an excessive 
mobility. The kidneys are pressed back into their 
place by two forces — one from above pressing the 
kidney downward and backward, and one from be- 
low pressing it upward and backward — the wedge- 
like backward pressure keeping the kidney in its 
normal position. The effect of this pressure can 
be seen on kidneys that have not undergone post- 
mortem or ante-mortem change from position of the 
body or disease — the anterior surface of the kidney 
appears prominent transversely at its centre, and falls 
off on an inclined plane towards its superior and in- 
ferior extremities. This wedge-like pressure is pro- 
duced on the right side from above by the liver, on 
the lower by the colon ; on the left side it is pro- 
duced from above by the suprarenal capsule, stomach 
and spleen, and on the lower by the intestines, which 
press upwards and backwards. On the right side, as 
the liver, kidney and colon move together during 
respiration and bodily position, the relative forces are 
usually about the same, but on the left side there is 
a greater degree of mobility, due to the varying con- 
dition of the intestines — the upward and backward 
pressure being less when the intestines are empty, 
and greater when they are distended with gas — the 
general pressure upward and backward upon both 
kidneys is generally maintained, but the lower force 
is the weaker, consequently anything which de- 
minishes the upward and backward pressure will 



2 2 NEPHROPTOSIS. 

be a factor in the production of, or will cause 
a movable kidney. Childbirth is undoubtedly the 
most frequent cause of a displaced kidney, some au- 
thorities claiming that one in every six or seven 
women who have borne children suffer from this 
condition. The majority of recorded cases occur be- 
tween the twenty-fifth and thirty-fifth year, yet Dr. 
W. W. Stewart, in the Medical Record, Feb. 9th, 1895, 
reports a case occurring in an infant of eight months. 
Edebohls, in a report of twenty-two consecutive cases, 
found fifteen in unmarried and seven in married 
women. Other authorities believe that corsets are 
the most frequent cause, but this has been largely 
disproven by the fact that German women of the 
lower classes, who never wear corsets, are especially 
prone to this condition. Falls and injuries, and the 
lifting of heavy weights, sometimes appear to be the 
exciting cause. Rapid absorption of the connective 
tissue surrounding the kidney in acute or chronic 
wasting disease, or the acute over-distention of the 
kidney, with rapid reduction of its volume, as in 
acute hydronephrosis, etc., often produce this con- 
dition. The faulty position of the body in sitting 
or standing, as well as an improper mode of dress- 
ing, are believed to be predisposing factors. It is 
almost seven times as frequent in the female as in the 
male, that is, according to the statistics, but as physical 
examination becomes more complete, we will probably 
not find the ratio of difference so large. The right 



NEPHROPTOSIS. 23 

kidney is usually the one to be dislocated or mov- 
able, and is believed by some to be due to the 
downward pressure of the liver. In a few reported 
cases both kidneys have been movable. 

Clinical History. — The movable is usually much 
more painful than the floating kidney, and is said to 
be fifty times as frequent in occurrence. In many 
eases no unpleasant symptoms are perceived, and the 
condition passes unnoticed only to be revealed at the 
autopsy, or accidentally discovered by the patient when 
the fear of a tumor of some kind necessitates medical 
advice, and the nature of the condition is thus re- 
vealed. These probably constitute the larger class. 

In the second class there is a sensation of some- 
thing wrong or loose within the abdominal cavity, ac- 
companied by flatulence, nausea and possibly vomit- 
ing, palpitation of the heart, also obscure gastro- 
intestinal and nervous phenomena, with varied mental 
symptoms, melancholia, etc. There is transitory or 
continuous pain, which at times is excruciating, in 
the region of the involved kidney, extending into the 
labia in the female, the testis in the male, down 
the groin and along the course of the anterior crural 
nerve. 

In the third class, when the pedicle is long and 
the kidney excessively movable, the ureter and its as- 
sociated vessels may become temporarily twisted or 
strangulated, causing agonizing pain, vomiting, disten- 
tion of the abdomen, collapse, etc., a condition known as 



24 NEPHROPTOSIS. 

Deith's or the renal crisis, which is due to the torsion 
and pressure on the vessels and nerves of the cord, 
and over-distention of the ureter and pelvis of the 
kidney by retained urine The torsion, however, soon 
rights itself by over-distention of the ureter, and the 
symptoms disappear, though in many cases it causes 
a hydro- or pyonephrosis. 

As a rule, there are no urinary symptoms of special 
importance, except those of a resulting acute hydro- 
nephrosis — i. e., small quantity of urine passed during 
an attack, followed later by the passage of a much 
larger quantity of light color. Before and during an 
attack of renal crisis there is frequent and some- 
times painful urination. 

The nervous symptoms are legion, being largely 
the reflex manifestations found in various uterine dis- 
eases: — nervous irritability, hysteria, hypochondriasis, 
melancholia, etc. In some cases the nervous con- 
dition becomes so pronounced as to result in hallucin- 
ation of sight, hearing, and even insanity. Sleep is dis- 
turbed or absent, many find it impossible to lay on the left 
side. The reason for these reflexes is, as yet, unknown. 
Edebohls believes that these nervous reflexes, as well 
as many of the digestive symptoms, are due to pres- 
sure upon the great solar plexus of the sympathetic 
nervous system. Changes in the circulation, and an 
almost cyanotic condition, accompanied by a sensation 
of constriction in various parts of the body, are often 
noticed. With these circulatory changes there is fre- 
quently great pain in the hands and fingers. 



NK1MIWOPTOSIS. 25 

The stomach and duodenum are frequently dis- 
located and distended with gas. Pain, often burning 
in character, is quite constant and may be felt 
in the region of the kidney, or more frequently 
along the free border of the ribs of the corresponding 
side. The mouth may be ulcerated, the gums spongy, 
and the tongue thick, red and sore, showing the im- 
print of the teeth. There may be constipation or 
alternate diarrhoea and constipation, and at times 
pieces of membrane or fibrous masses, from one- eighth 
to two inches in length, are passed with the stool. 
Patients sometimes complain of a sensation as if some- 
thing were alive in the abdomen. 

On inspection, the lumbar region over the mov- 
able kidney is found to be somewhat hollowed, 
and may be tympanitic instead of flat on percus- 
sion. The kidney may appear as a tumor, re- 
sembling in form a normal kidney, below the free 
ribs on the anterior portion of the abdomen, in the 
umbilical region, or even across the centre of the ab- 
domen. This tumor slips easily from beneath the fin- 
gers, and if the patient assumes the dorsal position, 
it can usually be replaced in its normal position, 
and the tympanitis in the lumbar renal region will 
then give place to flatness on percussion. It should, 
however, be remembered that the normal kidney 
has a range of motion of three-fourths to one 
inch in a vertical direction, and that the term 
movable kidney can only be applied when it exceeds 



26 NEPHROPTOSIS. 

this limit of mobility. In the very fat it is some- 
times impossible to make a diagnosis by the physical 
signs. 

The pain and the nervous and dyspeptic symptoms 
caused by a movable or floating kidney, have frequently 
been attributed to a diseased ovary and that innocent 
organ has been removed without cause and without 
relief to the unhappy patient. 

In the female, the symptoms are all worse during 
the menstrual period and during the first one or two 
months of pregnancy, due to the heavy and prolapsed 
uterus dragging down the kidney and other abdo- 
minal organs. When pregnancy advances or tumors 
develop, pushing up the abdominal viscera, relief from 
the symptoms frequently occurs. 

The clinical history varies somewhat with the 
kidney involved. If it is the right, flatulence, indi- 
gestion and vomiting will be prominent symptoms. 
The indigestion will not depend upon the character 
of food taken, and the pain accompanying it usually 
appears about two hours after eating. The pain and 
disturbed digestion is caused by a mechanical kink- 
ing in the duodenum from the sagging of the dis- 
placed kidney when the connecting band of tissue 
is firm; when it is loose the symptoms may be very 
slight. These gastric crises resemble those occurring 
in stricture of the pyloric end of the stomach and differ 
greatly from the renal crisis caused by the twisting 
of the ureters. When the left kidney is involved, the 



NEPHROPTOSIS. 2J 

gastric symptoms are absent and constipation becomes 
a prominent symptom. 

In a paper on this subject, Dr. A. H. Cordier, 
Medical Record, 1896, draws the following deductions: 
(1) A movable kidney often produces a dilatation of 
the stomach with all the accompanying symptoms of 
disease of that organ. (2) It is a fruitful source of 
gall-stones, because of the pedicle producing a partial 
obstruction of the common duct. (3) The bending of 
the ureter often gives rise to hydronephrosis ; this, 
in turn, is sometimes converted into pyonephrosis. 
(4) It may produce death by strangulation from tor- 
sion of the vessels and ureter. (5) By dragging on 
the abdominal aorta and kinking the vena cava, a 
condition simulating an aneurism of the vessels may 
be produced. (6) Pain, which is referred to the 
region of distribution of the spinal nerves, is often 
induced by a movable kidney through disturbance of 
the abdominal brain. (7) General nerve exhaustion 
often results from interference with digestion, as- 
similation and elimination. 

Diagnosis. — When examining for a movable kidney, 
three positions are recommended. First: The patient 
is placed in the dorsal position with the shoulders 
elevated, thighs flexed upon the abdomen and requested 
to make deep inspirations and expirations to relax 
the abdominal muscles. The hand is then placed 
underneath the hollow of the loin, and just be- 
tween the last rib and the crest of the ilium, the 
thumb encircling the abdomen immediately below the 



2 8 NEPHROPTOSIS. 

costal arch but without exercising any pressure. As 
expiration is about to commence, the thumb is pressed 
upward beneath the costal arch and as deeply as 
possible toward the kidney, at the same time the kid- 
ney is brought forward by the pressure of the fingers 
from behind. If the patient is not too fleshy, a dis- 
located kidney may be made out by placing the other 
hand below the thumb and its abnormal mobility 
demonstrated. When the kidney lies entirely below 
the grasp of the hand we have a movable kidney. 
As the grasp is relaxed, the kidney is liable to slip 
easily from the hand into its normal position. Deep 
pressure frequently causes a sickening nauseated feel- 
ing. A kidney that descends only so that its lower 
half can be felt on inspiration and recedes with ex- 
piration, must be considered as physiologically mov- 
able. If the mobility cannot be determined in the 
dorsal position, the patient should recline on the side 
opposite the kidney to be examined — then, with bi- 
manual examination and deep inspiration, as above, 
the diagnosis can usually be made. These methods, 
however, are objectionable, as the bodily position 
facilitates the return of the kidney to its normal position, 
and, in those who are very fleshy, it is impossible, 
or very difficult, to grasp the kidney between the 
hands. When, however, the patient stands with the 
shoulders bent forward, the kidney will be strongly 
displaced and can usually be mapped out with the 
finger as it presses against the abdominal wall. 



NEPHROPTOSIS. 29 

This condition must be differentiated from growths 
in the mesentery, from the pancreas, a wandering 
spleen, a diseased gall-bladder or ovary. These can 
usually be eliminated by their clinical history. The 
enlarged gall-bladder, when movable, moves in a circle, 
and, when distended with gall-stones, is harder and 
more tense than a movable kidney; the accompany- 
ing jaundice will assist in the diagnosis, although 
an exploratory incision is sometimes required to make 
it clear. 

Treatment. — Do not neglect the administration of 
the indicated remedy simply because you have a sur- 
gical condition to deal with; but do not rely on drugs 
alone ; the parts at the same time must be restored 
to their normal position and properly supported. The 
remedies most frequently indicated are : Strychnia 
arseniate, Pulsatilla, Sulphur, Ignatia, Grelsemium and 
Lachesis. In acute cases replace the kidney. Rest in 
the dorsal position, hot fomentations, hot baths, and 
sometimes, in the renal crisis morphia may be required. 

There are four methods of treating chronic 
cases : First, rest, and if this treatment is to be fol- 
lowed, it means absolute rest — no carriage, bicycle 
or train rides ; no walking, climbing, jumping, danc- 
ing, etc. Few patients, however, can afford abso- 
solute rest. Next in order comes the use of a 
proper belt or bandage. Newman uses a rubber pad 
which can be inflated after adjustment. Others use 
elastic webbing, applied so as to completely surround 



30 NEPHROPTOSIS. 

the abdomen. This acts well in the male and in 
females who are free from uterine disorders. A simple, 
broad bandage, with a broad pad, sometimes acts very 
satisfactorily. A tight corset or a spring truss, fur- 
nished with a large pad, to compress and push 
upwards the lower part of the abdomen, have also 
been advised. Of the various kinds of supports, the 
best satisfaction has been given by a silk elastic 
abdominal belt, with perineal straps to retain it in 
position, as advised by Dr. W. W. Stewart, in the 
Medical Record, Feb. 9, 1895, and made by 
Pomeroy & Co. In some cases a pad of horse-hair 
or wool, covered with kid, and placed just below the 
kidney, is required. 

The greatest care is necessary in taking the meas- 
urements from which the belt is to be made. These 
measurements are to be taken at eight distinct points, 
as per Figure 1. The patient should stand squarely 




FIG. 1. 



NEPHROPTOSIS. 3 I 

on the feel while measurements are being taken, and 

the tape should be drawn uncomfortably tight at each 
point. The belt should always extend as high as the 
last rib and lit snugly. 

Dr. S. A. Newhall, in the Kansas City Medical 
Arena, records a case cured by Faradism, one pole 
being applied in the vagina and the other over the 
kidney region. The current was used daily, and 
after the third application the kidney returned to 
its normal position and remained there. The treat- 
ment was continued daily for two weeks, and then 
every second day for two weeks longer. In many 
cases excellent results are obtained with Faradism, 
combined with a proper abdominal bandage and the 
usual hygienic restrictions. When these means are not 
successful, and the kidney is healthy, a nephrorrhaphy 
must be performed, and the movable or floating kid- 
ney fixed to the posterior wall of the abdomen; if it 
is diseased, the organ must be removed (see neph- 
rorrhaphy -nephrotomy). Bruce Clark says that mov- 
able kidneys tend to the development of calculous 
deposits in the pelvis of the kidney, interstitial 
nephritis, etc. ; when the operation to immobilize 
the kidney is delayed too long, he advises an early 
operation. Osier says that the operation is not always 
successful. 



CHAPTER III. 
UraBmia. 

Foster defines this condition as "a poisoned state 
" of the blood, due to defective elimination of the 
" elements of the urine, in consequence of impair- 
"ment of the functional capability of the kidneys, or, 
"by their re-absorption in the cases of retention of 
"urine, characterized by stupor and, especially in 
"lying-in women, by convulsions." 

Etiology. — When the condition that we now recog- 
nize as uraemia was classified, it was supposed to be 
due to the retention or an excess of urea in the 
blood, but as experiments multiplied, it was found 
that uraemic symptoms were sometimes present when 
the blood contained no urea, although if urea were 
introduced either directly into the blood current, or 
indirectly through the stomach, and the ureters tied, 
or no fluids ingested, many symptoms of uraemia 
soon appeared. It has further been found that many 
cases of complete anuria were not followed by 
uraemia. This and other facts lead to the rejection 
of this theory, and the advancement of the idea that 
uraemia only occurred when the urea in the blood 
was in some manner decomposed into the Carbonate 
of Ammonia by a peculiar organized ferment; but in 
the light of modern investigation, this theory, like the 



UREMIA. 33 

one that it was produced by the excretory products, 
Creatin, Creatinin, Leucin and Tyrosin proved falla- 
cious. Then followed the theory of Traube that the 
condition was the result of cardiac hypertrophy, 
hydraemic conditions of the blood, and cerebral 
oedema, but this, too, was found to be fallacious, or 
not true in all cases. The Jour, de Med. et de 
Chir. Pratique, July 10, 1895, says that uraemia is 
caused by the following conditions, which may be con- 
sidered to be the opinion of the day: "First, a domi- 
nating toxic element, caused by the failure of the 
diseased kidney to perform satisfactory elimination of the 
debris of the organism. Second, a mechanical factor, 
cerebral anaemia, the localization of which in the motor 
zones may cause convulsions, either general or limited 
to one side, to one member or merely to several facial 
muscles. In some cases the uraemia presents an 
apoplectic form, in others it is hemiplegic, both de- 
pendent, however, upon cerebral anaemia." The writer 
further remarks that many cases of hemiplegia, 
usually supposed to be due to cerebral hemorrhage 
or softening, in which the autopsy shows no evidences 
of disease or extravasation of blood into the cerebral 
tissue, are due to this cerebral oedema, which disappears 
on the death of the subject. We must, therefore, await 
further research, believing it to be due to some de- 
ficiency of elimination of certain unrecognized elements, 
and content ourselves with a description of the effects, 
the remedial treatment, and the physiological methods 
at our command to relieve or prevent them. 



34 URiEMIA. 

Headache is one of the early symptoms of this 
condition, which we call uraemia. It may be mild, 
severe, transitory or continuous; in some cases it is 
so intense and protracted as to cause sleeplessness. 
In the acute forms of nephritis it is accompanied by 
arterial tension and diminished secretion of urine. 
In the chronic form the urine is often diminished, 
the specific gravity low and the arterial tension is 
not constant. 

Uremic Amaurosis. — Sudden blindness, not due to 
retinitis albuminuria, is sometimes developed during 
the puerperal state, and in chronic nephritis. The 
cause of this symptom is unknown. It may last for 
hours or days, and may precede or follow convulsions; 
it is sometimes accompanied by uraemic deafness. 

Contractions of single muscles or groups of mus- 
cles sometimes occur in the more severe cases of 
uraemia, and are usually the forerunner of the ap- 
proaching convulsion. 

Convulsions. — Their appearance is usually sudden; 
there may be one or many, and they may follow each 
other at intervals of minutes or hours. They may 
be epileptiform in character or assume the Jacksonian 
type. Consciousness may return between the attacks 
or the patient may remain in a state of coma; con- 
vulsions may develop in mild as well as in the more 
severe cases of acute nephritis, and may be expected 
when the urine is diminished or suppressed with 
marked arterial tension. In these, recovery is the 
rule. When occurring in chronic interstitial nephritis 



URiEMIA. 35 

and in the puerperal state, developing before, during, 
or after labor, accompanied with the same arterial ten- 
sion and urinary symptoms as inacute nephritis, the 
termination is more likely to be fatal. 

Delirium and Coma may appear in uraemic con- 
ditions. These, with convulsions, may develop slowly 
or rapidly during the course of Bright's disease, es- 
pecially in the acute and in the exacerbations of chronic 
nephritis. The coma may be continuous, progressive 
or transitory. The face may be pale or flushed; the 
pupils dilated, contracted or normal. The breathing 
is often hissing in character, and is noticed in the 
more severe forms of Bright's disease. 

Aphasia of uraemic origin has been noticed by 
Rendu, Gruyot and others. Rendu's case in the Hos- 
pital Xecker seems to prove that the uraemic toxine 
may be limited to a particular area of cerebral tissue 
or a general involvement, as was originally maintained. 

Insanity frequently develops and is often over- 
looked; it occurs especially in chronic interstial 
nephritis. The patient is restless, sleepless, talkative 
and noisy. 

Temperature. — In chronic Bright's, when the head- 
ache, coma, convulsions, delirium, etc., become marked, 
there is usually a corresponding rise of temperature, 
the thermometer sometimes registers 108° to 109° F. 
In acute cases a temperature of 103° or 104° F. for 
the first week is not uncommon. 

Arterial Tension. — This is one of the most fre- 
quent and grave phenomena noticed in uraemic con- 



36 URAEMIA. 

ditions; it accompanies most of the severe manifesta- 
tions. When the ursemic conditions are prolonged, 
hypertrophy of the muscular coat of the arteries may 
develop, but the principal cause of the tension is 
undoubtedly due to irritation of the inner coat of the 
arteries by some toxic substance or substances in the 
blood which the kidney has failed to eliminate. 

Dyspncea in Bright's disease may arise from many 
causes: From an accumulation of fluid in the pleural 
or abdominal cavities, oedema of the lungs, accumu- 
lation of bronchial secretions, etc., but the true ursemic 
dyspnoea is from another cause, i. e., irritation and 
consequent poisoning of the respiratory centers from 
a substance contained in the circulation. This condition 
comes on insidiously — it is usually first noticed in the 
morning or after some unusual mental or physical 
exertion. At first the attacks of dyspnoea are trans- 
itory and are frequently the first symptom to indicate 
the presence of chronic Bright's disease. As the disease 
progresses the attacks appear at more frequent intervals 
and are of longer duration. The patient is unable to lie 
down and rales are absent in the bronchial tubes; 
this physicial sign differentiates it from bronchial 
asthma. After a time this condition becomes contin- 
uous and agonizing, the Cheyne-Stokes respiration may 
be present, and death finally releases the sufferer from 
his misery. 

Digestive Disturbances. — The breath frequently 
has the odor of urine. Vomiting may occur in both 
the acute and chronic forms of Bright's disease. In 



URAEMIA. 3 7 

acute cases it may be caused either by the urea in the 
circulation or the hyperpyrexia. In the more chronic 
form it may be distressing, sometimes lasting for days. 
The vomiting is especially noticeable in the morning, 
after taking food; is usually accompanied by increased 
arterial tension, and is very exhausting and may term- 
inate fatally. Diarrhoea sometimes occurs. 

Uremic Pruritus, formication, numbness and pain 
in the joints, simulating rheumatism, are occasionally 
complained of. 

Diagnosis. — In cases of doubt, the diagnosis will 
always depend on the urinary analysis. When 
the patient is unconscious, he must be catheterized 
and the urine examined without delay. The symp- 
toms of nephritis, objective and subjective, are usually 
all-sufficient to make a diagnosis, yet it is some- 
times impossible to differentiate the cerebral conditions 
from cerebral hemorrhage, tumors and meningitis. 
All objective symptoms being equal, if the eyes con- 
verge to the same point, the probable diagnosis will 
be apoplexy, and not ursemic coma. Epileptic con- 
vulsions simulate very closely those of uraemia, and 
albumen may even be present in the urine, but 
it occurs only during and immediately after an at- 
tack, while in uraemia it is persistent. Poisoning 
by narcotics also simulates uraemic conditions. In 
opium poisoning the respiration is slow and ster- 
torous. In uraemia it is asthmatic and hissing in 
character. 

Prognosis. — The prognosis is always grave. When 



38 UREMIA. 

occurring in acute nephritis, the patient usually re- 
covers. In chronic parenchymatous nephritis it is a 
symptom of approaching death, though relief may 
sometimes be given for a considerable period. In 
chronic interstitial nephritis it indicates impending 
death. 

Treatment. — The remedy indicated by the totality 
of the symptoms. 

Acid Carbolic. Great fullness of the cerebral ves- 
sels, sensation of a band around the head, headache, 
vertigo, clonic convulsions, coma, great languor of 
mind and body. 

Acid Hydrocyanic. Ursemic convulsions, with draw- 
ing backward of the head, respiration irregular, gasp- 
ing, great cardiac distress, coldness and blueness of 
the extremities. 

Ammonium carbonicum in the non-reactive state of 
uraemia, stupid in action, grasping at flocks, face and 
lips bluish, rattling as of large bubbles in the lungs. 

Arsenicum. Uraemia, with great anxiety, restlessness 
and sinking of the vital forces, with a feeling that it 
is useless to take medicine and that they are about 
to die; dysjmoea, either cardiac with palpitation, or 
due to oedema of the lungs, worse at night and when 
lying on the back; dyspnoea aggravated on lying down, 
especially recurring at 12 P. M., and relieved by 
expectoration. 

Cannabis Indicus. Uraemia, with severe headache, 
sensation as if the vertex was opening and closing, 
associated with delusion of time and space; objects 



UILEMIA. 39 

seem a long distance off, forget what they intend to 
say or do. 

Cantliarides. Headache, delirium, coma, with sup- 
pression of urine. This remedy frequently increases the 
flow of urine and prevents convulsions. 

Cicuta virosa. Convulsions, with twitching of indi- 
vidual muscles. 

Cuprum Arsenite. Uraemic convulsions. Groodno 
considers this remedy in the second or third deci- 
mal trituration almost infallible. 

Glonoin. Uraemic dyspnoea, uraemic convulsions, 
frothing at the mouth, pulse full and hard, un- 
conscious, with thumbs clenched into the palms. 

Helleborus niger. Blunting of the general sensibilities; 
pupils dilated and do not react to light, or while see- 
ing do not seem to regard the objects seen ; violent 
pain in the head, especially in the occiput ; face 
swollen and puffy, nausea, vomiting, absence of thirst; 
convulsions, with cold extremities ; urine scanty or 
suppressed. 

Opium. Uraemic coma and convulsions. 

For more complete symptomatology and minor 
remedies see Chapter XL. 

At the same time the adoption of physiological 
means are often imperative. Hot baths are useful 
and of great benefit. The removal of a portion 
of the blood, and with it a quantity of urea, with 
the transfusion of an equal quantity of a saline solution 
to take its place, has in many cases given imme- 
diate relief. One thousand grammes of blood charged 



4-0 URAEMIA. 

with urea have in this way been removed, and the 
balance of the circulation maintained by the saline 
solution with marked benefit ; a rectal injection of 
two quarts of a hot saline solution has often acted 
kindly and re-established urinary secretion. These 
methods are believed to be far more beneficial in 
ursemic conditions than diaphoretics or cathartics. 
When profuse sweating is desired, Pilocarpin is ad- 
missible only when simple hypertrophy of the heart 
muscle is present, without other heart complications. 
It is a heart depressant, and has frequently acted 
disastrously. Children are proportionately more 
tolerant of this drug than adults. 

When arterial tension is present, most authorities, 
at the present time, advise the administration of 
Grlonoin, Chloral Hydrate or Morphia, as indicated 
by their physiological action, to relieve the tension 
and, for the time being, remove the strain upon the 
system. 

Free purgation has sometimes been of great bene- 
fit. When the patient is unconscious, this is best 
produced by placing a drop of Croton Oil on the 
finger and applying it to the back of the tongue ; 
when able to take medicine, Elaterium, in ifo to 
}& grain doses every four hours, or an ounce of 
Magnesium Sulphate dissolved in an ounce and a half 
of water, may be given early in the morning, the 
patient taking no fluids for twelve hours before it, 
and not until six hours afterwards, have acted satis- 
factorily. 



CHAPTER IV. 
Acute Congestion of the Kidneys. 

Etiology. — This condition is frequently caused 
by excessive and unusual exertion, as in baseball 
and football games, bicycling, mental excitement, 
and from cold baths or exposure. It may be the 
result of severe bodily injury, or surgical opera- 
tions, especially those connected with the genito- 
urinary system. It is frequently caused by irritant 
drugs, as Cantharides, Turpentine, Ether, Chloroform, 
etc., when ingested, inhaled as vapors, during their 
elimination, or following their local application to 
various parts of the body. 

Pathological Anatomy. — There is no change in 
the structure of the kidney. The blood vessels are 
more or less engorged, depending upon the severity 
of the attack. 

There may be an exudation of serum and leu- 
cocytes, or diapedesis of red blood cells into the 
tubes and glomeruli. 

Upon recovery the kidneys return to their normal 
condition. 

Clinical History. — In itself it is of importance 
as being part of or accompanying some other con- 
dition. This disease is usually transitory and soon 
subsides. It may, however, develop into an acute ne- 
phritis, and in some cases may, especially after surgical 



42 ACUTE CONGESTION OF THE KIDNEYS. 

operations, particularly those of the genito-urinary tract, 
prove rapidly fatal, death occurring in one or two 
days. It may, on the other hand, pass into a 
typhoid condition, and after giving marked indica- 
tions of ursemic poisoning, terminate in recovery. 

When the cause has been the administration of 
Cantharides, Turpentine, etc., the general symptoms 
will vary with the quantity of the drug introduced 
into the system. There will be some rise in tem- 
perature, nausea, vomiting and diarrhoea, pain in the 
loins, frequently extending across the abdomen, with 
moderate stupor and delirium. When from over- 
exercise the general symptoms, except the change 
in the urine, frequently pass unnoticed. This fact 
is well demonstrated by cases reported by Dr. 
Andrew Macfarland in the Medical Eecord of Dec. 
22, 1894. He carefully examined the urine of the 
members of a football team before and after the 
game, and though in each case there was no clinical 
evidence of disease, he found albumen, casts and 
epithelia in the urine, which entirely disappeared, 
and the urine, in from a few hours to a few days, 
returned to a normal state. 

The clinical history therefore may be said to vary 
greatly. 

The urine is albuminous and smoky; it may con- 
tain red blood corpuscles and tube-casts of various 
kinds, especially hyalin. The urine of the football 
players referred to above contained large and small 
granular blood and epithelial casts. 



ACUTE CONGESTION OF THE KIDNEYS. 43 

] Prognosis depends upon the cause. If from excessive 
bodily exercise, recovery almost always occurs, unless the 
cause is too often repeated, when it may be the beginning 
of a serious kidney lesion. If from poison, it will de- 
pend upon the quantity taken in the system. If from 
surgical operation, the result will depend upon the 
severity of the original cause, though some surgical 
cases die from congestion of the kidneys, even when 
the operation has been comparatively trivial. 

Treatment. — If the congestion is from over-exertion, 
Arnica, Sandalwood or Aconite; from exposure, Aconite, 
Dulcamara, Belladonna or Rhus tox; from surgical oper- 
ations, shock or mechanical injuries, Veratrum viride, 
Aconite, Arnica, or Belladonna; when associated with 
gastric or hepatic disturbances, pain in the back, etc., 
Mercurius corrosivus, Cantharides, or Terebinth. For 
general symptomology see Chapter XL. 

Rest in bed is of great importance. Baths at 
a temperature of 100° F. Hot packs over the loins 
and hot foot baths, with an absolute milk or fluid diet 
and an abundance of pure (not hard) water, preferably 
Poland or Hygeia, are always indicated. 

Acute congestion of the kidney, resulting from 
surgical operations, are very liable to prove rapidly 
fatal and the best directed treatment will often fail. 
If the lesion has been caused by poison, administer 
an antidote and eliminate the poison as soon as pos- 
sible from the stomach and system. When from Can- 
tharides, give two to four grains of Camphor every two 
to four hours, as an antidote, whether the drug has 
been introduced by the mouth or in the form of a blister. 



CHAPTER V. 
Chronic Congestion of the Kidneys. 

Etiology. — This condition is caused by venous 
stasis in the renal circulation due to weakness in the 
heart-power, from chronic endocarditis, myocarditis 
or dilatation, aneurism of the arch of the aorta, pul- 
monary emphysema or carnification ; also by the 
long continued presence of pathological fluids in the 
pleural sac. It is a frequent concomitant of chronic 
cardiac lesions, but it appears only when there has 
been sufficient loss of the heart tone or power to 
allow the venous blood to accumulate abnormally in 
the veins of the kidneys. 

Pathological Anatomy. — The kidneys may be 
large or normal in size. They are proportionately 
heavier and firm in consistency. The surfaces are 
smooth and capsules non-adherent. They are dark 
in color, but there is a marked contrast between the 
pyramids and cortex, the latter being somewhat paler 
and of a bluish-gray tint. 

The cells covering the capillary tufts are swollen, 
some of the cells lining the glomeruli are swollen 
and opaque, others are normal. 

In the tubes of the cortex the epithelium may be 
swollen or flattened. The swollen cells are granular. 
The lumen of the tubes may contain fibrin, leucocytes 
and red blood cells. The stroma is unaltered. 



CHRONIC CONGESTION OF THE KIDNEYS. 45 

Clinical History. — This disease may be sus- 
pected when there is a history of marked pulmonary 
emphysema, or carnification caused by chronic pleuritic 
adhesions, or from any weakness of the heart power. 
The clinical manifestations of patients suffering from 
chronic congestion of the kidneys will vary greatly 
with the concomitant pathological conditions which 
are associated with it, both from the original cause 
and other renal lesions, i. e., chronic degeneration, 
interstitial or parenchymatous nephritis. 

The urine is scanty, dark in color, of high specific 
gravity, and, on standing, deposits large quantities 
of urates and uric acid. Albumen is sometimes pres- 
ent in small quantities, together with a few hyalin 
casts and red blood corpuscles. Dropsical conditions 
arc frequently present, the oedema being confined to 
the lower extremities, while the upper extremities 
and face escape, thus assuming the character of a 
cardiac dropsy. There is a diminished secretion of 
urine, accompanied by gradual loss of strength and 
flesh, nausea, vomiting, headache, delirium, coma, and 
possibly convulsions. In other cases, a typhoid state 
may develop. 

The remedies will be those which best correspond 
to the general condition of the patient. 

Treatment. — Arnica has been given with satis- 
factory results when there was general dropsy with a 
bruised feeling of the body. Convallaria when from 
cardiac dilatation and hypertrophy ; heart's action 
rapid and irregular, with general anasarca and lame feel- 



46 CHRONIC CONGESTION OF THE KIDNEYS. 

ing in the back, aggravated by lying down. Digi- 
talis when there are suffocating spells, sinking, faint 
feeling at the pit of the stomach, feels as if about to 
faint, pulse feeble and low: renal congestion, due to en- 
feebled muscular power of left ventricle. Phosphorus in 
renal congestion, due to loss of muscular power of 
right ventricle; weak, empty feeling in whole ab- 
domen. If the cause can be removed or ameliorated, 
much comfort and relief can be given the patient. 
When caused by cardiac disease, physiological treatment 
may be indicated. An over-acting heart, or excessive 
action, due to contraction of the arterioles will re- 
quire Nitro-glycerine. If there is simple over-action 
Aconite, Belladonna or Veratrum-viride may act sat- 
isfactorily. If there is want of tone or weakness, 
Digitalis, Strychnine, Caffein, or Strophanthus. Dela- 
field advises small doses of Codeia or Morphia in the 
later stages of chronic congestion of the kidneys from 
aortic and mitral stenosis or myocarditis, with dis- 
ease of the coronary arteries. 

Hot air baths may be required, and sometimes 
prove very beneficial. 

Rest in bed is frequently very important, and good 
nourishing food, especially animal diet, should be ad- 
vised. 



CHAPTER VI. 
Acute Nephritis. 

Etiology. — Its most frequent causes are exposure 
to cold and damp, mechanical injuries or irritation from 
calculi. It is most frequent in the aged, and is a 
disease mostly prevalent in damp climates. 

Clinical History. — One kidney alone is involved. 
The disease begins with a chill, and is followed by 
high fever, with dull pains over the affected kidney, 
aggravated by motion and pressure. The pain may 
radiate to the umbilicus, down the thigh, and along 
the course of the anterior crural nerve; the testicle 
on the side involved is usually retracted. Nausea and 
vomiting accompany the early symptoms, diarrhoea 
and tenesmus are not infrequent. The urine is scanty, 
high colored, with increased specific gravity, and may 
contain blood and some albumen; micturition is fre- 
quent. 

Prognosis is favorable ; recovery usually occurs in 
from one to three weeks, although it may result in 
suppuration. 

Treatment. — That directed for acute parenchymatous 
nephritis. 



CHAPTER VII. 
Acute Degeneration of the Kidney. 

Etiology. — Conditions of the blood dependent upon 
acute and infectious diseases often cause renal de- 
generation. It is also caused by the presence in the 
system of certain mineral poisons, as Arsenic or 
Phosphorus. The Bi-chloride of Mercury has fre- 
quently caused it when used as an antiseptic dressing 
or douche, and Weilander, in Univ. Med. Journal, 
Aug., 1894, from Hygiea, 1894, reports that this con- 
dition was noticed in ninety-seven cases of syphilis 
while under mercurial treatment, which disappeared 
when the drug was eliminated from the sys- 
tem. The degree of degeneration, or death of the 
epithelium, and the quantity of exudate from the blood 
vessels will vary with the amount of the poison in- 
troduced into the system. As a concomitant of infec- 
tious diseases, the degree of acute degeneration varies 
with different epidemics ; why, we do not at present 
know, but the pathological changes, whether caused 
by an acute infectious disease or a mineral poison, 
are identical. 

Pathological Anatomy. — The kidneys are in- 
creased in size. The surfaces are smooth and the 
capsules non-adherent. The cortical portion is thick- 
ened and pale. 

The changes which take place are in the pa- 



n \ i E i. 




c 



(MAGNIFIED 45c DIAMETERS.) 
FIG. I. 

ACUTE DEGENERATION OF THE KIDNEY. 

a. Degenerated epithelium, b. Lumen of tubule obliterated by swollen 

and necrotic epithelium. 




('MAGNIFIED 450 DIAMETERS.) 

FIG. 2. 

CHRONIC CONGESTION OF THE KIDNEY. 

a. Capillary tuft, showing a swelling of the epithelium and dilated cipillaries. 

/'. Swollen epithelium of tubules, c. Flattened epithelium, d. Flattened 

epithelium, detached from wall of tubule. 



ACL'TE DEGENERATION OF THE KIDNEY. 49 

renchyma of the organ, and more markedly in the 
convoluted tubules. 

The epithelium lining the tubules and glomeruli, 
and that covering the capillary tufts of the glomeruli, 
is swollen and opaque ; sometimes the swelling is 
so great as to completely fill up the lumen of 
a tubule. The swollen cells may be infiltrated with 
granular fatty substance: some of the cells become 
detached from the wall of the tubule, or a part of 
the cell may tear off and drift away as granular 
debris. 

In the lumen of the convoluted tubules may be 
seen hyaline material, and in the straight tubules de- 
tached epithelium and hyalin casts. 

Clinical History. — Is important only as an ac- 
companiment of acute infectious diseases — measles, 
scarlet fever, typhoid or yellow fever and pneumonia, or 
in cases of poisoning by Mercury, Arsenic, Phosphorus, 
etc. It is not accompanied by dropsy or arterial ten- 
sion. It is usually transitory in nature, and as the 
condition causing it is removed or disappears, the 
parts return to their normal condition. When follow- 
ing a severe case of mineral poisoning, or accom- 
panying acute infectious diseases, as yellow fever, etc., 
delirium, convulsions, coma, and death sometimes oc- 
cur, though it is often difficult to say whether death 
is due to the kidney lesion or to the action of the ori- 
ginal cause in other organs of the body. Micturition is 
increased in frequency, and the urine is usually di- 
minished in quantity or suppressed. It has a smoky 



50 ACUTE DEGENERATION OF THE KIDNEY. 

appearance, contains albumen, blood and casts ; the 
specific gravity is normal, or slightly increased. It 
should be always remembered that in the acute in- 
fectious diseases, acute degeneration of the kidney 
appears especially in the early stages, while acute pa- 
renchymatous nephritis occurs late in the history of 
the case, and its prognosis is far more grave. 

Treatment. — The remedies most frequently re- 
quired are Belladonna, Cicuta vir., Arsenicum, Apis 
mel., Terebinth and Rhus tox. For special indications 
see Chapter XL. 

If caused by a mineral poison, remove it at once 
and administer an antidote. If from an infectious 
disease, its treatment will generally suffice. 



CHAPTER VIII. 
Chronic Degeneration of the Kidney. 

Etiology. — The principal cause is obstruction to 
the circulation from cardiac or pulmonary disease. It 
occurs sometimes without apparent reason. It may 
be due to the cachexia which accompanies catarrhal 
phthisis, pulmonary tuberculosis, cancer, etc. It 
seems to be a grade beyond a chronic congestion of 
the kidney, and is characterized by degeneration ot 
the epithelia lining the urinary tubules. 

Pathological Anatomy. — The kidneys are enlarged 
and two or three times heavier than normal. Their 
surfaces are smooth. The markings are very distinct. 
There is a decided contrast between the cortical and 
pyramidal portions — the former being pale and thick- 
ened, the latter hypersemic and dark. 

The epithelium lining the convoluted tubes is 
swollen and granular, the cells covering the capillary 
tufts of the glomeruli are swollen and the capillaries 
themselves are dilated. The veins of the pyramids 
are engorged. 

Sometimes the kidneys are not enlarged and show 
no change in the gross appearance other than con- 
gestion of the pyramids. 

Clinical History. — The condition is very often 
overlooked. The urine may appear normal, or from 
time to time contain a small quantity of albumen and 



52 CHRONIC DEGENERATION OF THE KIDNEY. 

a few casts; this is especially true in cases caused by 
grave chronic constitutional disease, or unknown 
causes. When the condition accompanies chronic heart 
lesions, the urine may vary in quantity, and often 
becomes scanty or suppressed. The specific gravity 
is about normal, and the percentage of urea is scarcely 
affected. Chronic degeneration of the kidneys does 
not of itself cause dropsical symptoms, interfere with 
the heart's action, or produce uraemia. There is an 
interference with the power of assimilation and, con- 
sequently, progressive weakness and emaciation, which 
may finally become so marked as to cause death from 
asthenia. 

Treatment. — The remedies most indicated are Phos- 
phorus, Arsenicum, Rhus tox, etc. For symptomatology 
see Chapter XL. The diet should be liberal, easy of 
digestion and assimilation. The general hygiene and 
regulation of the habits of the patient must receive 
proper attention, and the original cause removed or 
ameliorated. 



CHAPTER IX. 
Acute Parenchymatous Nephritis. 

Acute Blight's, Acute Croupous Nephritis, Post 
Scarlatinal Nephritis, Tubal Nephritis, etc. 

Millard describes this condition as a nephritis char- 
acterized by exudation into and infiltration of the 
connective tissue with secondary changes in the epith- 
elium, the whole leading to the formation of casts and 
being invariably accompanied by albuminous urine. 
Delafield divides this condition into the Acute Exuda- 
tive and Acute Productive Nephritis. Acute exudative 
nephritis he describes as an inflammation of the kid- 
neys characterized by congestion, exudation of the 
blood plasma, emigration of the white blood-cells, dia- 
pedesis of the red blood-cells, to which may be added 
changes in the renal epithelium and in the glomeruli: 
and acute productive nephritis as an acute inflammation 
of the kidneys, characterized by exudation from the 
blood-vessels, a growth of new connective tissue in 
the stroma and changes in the epithelium and glom- 
eruli. The pathological changes of these two forms 
are easily recognized in their morbid anatomy, and 
usually can be differentiated diagnostically. As their 
clinical histories are similar, they will be classed 
under the general head of acute parenchymatous ne- 
phritis, and their differential diagnosis, pathological 



54 ACUTE PARENCHYMATOUS NEPHRITIS. 

anatomy, history, prognosis and treatment will all receive 
proper attention. 

Etiology. — This disease is most frequently met 
with in childhood, and is rare in those past forty 
years of age. When it occurs before the twelfth year, 
it is usually of the exudative variety; after that period 
the majority of the cases are sub-acute in character 
and of the productive form. 

This is readily explained when considering the ex- 
citing cause of these kidney changes. Among the 
most frequent causes leading up to the development 
of acute parenchymatous nephritis are exposure to 
draughts, especially after bathing or over-heating of 
the body, colds from getting wet, improper or un- 
seasonable clothing, etc. In childhood the most 
frequent cause is the presence in the blood of 
bacteria of infectious diseases or their ptomaines, 
which, passing through the kidneys in the process of 
excretion, produce at first irritation of the parenchyma 
of that organ and ultimately inflammation, which, if 
it is of the exudative variety, will be transient in 
nature, but if of the productive form will frequently 
result in chronic lesions of the kidney. The disease 
is therefore frequently found as a complication or 
sequela of measles, scarlet fever, small-pox, typhus, 
typhoid, cerebro-spinal meningitis, influenza, parotitis, 
catarrhal tonsilitis, diphtheria, pneumonia, chicken-pox, 
erysipelas, etc. The experiments of Vissman (Med. 
Record, Sept. 14, 1895) demonstrates that antitoxin is 
a common cause of acute parenchymatous nephritis. 



ACUTE PARENCHYMATOUS NEPHRITIS. 55 

The occurrence of this disease in the diseases 
mentioned varies greatly with the different epidemics. 
It has been noticed that it bears no special relation 
to the severity of the original infections disease. It is 
not infrequently a concomitant of acnte articular rheuma- 
tism. Extensive burns of the body have been known 
to cause it, and it so often follows constitutional cuta- 
neous lesions that they also may be considered as 
exciting causes. The disease also appears as a sequela 
of septic inflammation, surgical and puerperal fevers, 
anthrax, etc. 

Malarial conditions in many cases are undoubtedly 
the cause of this disease. During an attack of inter- 
mittent and of bilious remittent fever albumen and 
renal epithelia can almost always be found in the 
urine. It is generally believed that the presence of 
the bile acids in the blood, which, when excreted by 
the kidneys, irritate and lead to inflammation of the 
kidneys, explains this cause on the same principle as 
the well-known effect of Turpentine, Copaiba, Cubebs, 
Ginger, Arsenic, Corrosive sublimate, Potassium chlorate, 
Carbolic acid, Pyrogallic acid or Squills on that organ. 

The nephritis from the last named irritants is usually 
of the exudative variety, is transitory, and subsides 
on the removal of the cause. The same would be 
true of the nephritis developed in the malarial diseases, 
were it not for the fact that the attacks are usually 
frequently repeated, and these repeated attacks may 
develop a productive nephritis and ultimately a 
chronic nephritis. Sometimes an acute parenchyma- 



56 ACUTE PARENCHYMATOUS NEPHRITIS. 

tous nephritis will engraft itself without any discover- 
able cause on any one of the more chronic forms of 
Bright's disease, although these apparently new in- 
vasions in chronic nephritis must be considered only 
as exacerbations. 

Bacteria in the blood, independent of any of the 
known bacterial diseases, have been known to cause 
acute parenchymatous nephritis, by their presence in 
the kidneys during the process of elimination, the 
lesion developing rapidly and terminating in uraemia 
and death. These bacteria are rod-shaped and re- 
semble the micro-organisms found in the blood of 
those suffering from typhus. In the bacterial form of 
acute parenchymatous nephritis the bacteria after death 
are found not only in the kidneys, but also in the blood 
and urine. When these bacteria are cultivated even to 
the fourth generation, and rabbits are inoculated with 
the culture, the same lesion of the kidney is produced. 
This bacterial form of acute nephritis accounts for many 
cases which would otherwise be mysterious in origin, 
though we should remember that the presence of bac- 
teria in the urine does not necessarily mean pathological 
changes in the tissues, for bacteria do appear in the 
urine when all the organs are in a healthy state, as 
after drinking impure water or eating old cheese. 
There is also a certain inherent condition of the blood, 
without bacteriological contamination, which will, in 
itself, act as an irritant and induce nephritic inflam- 
mation. 

Pathological Anatomy. — The acute exudative type 



PLATE II. 




(MAGNIFIED 450 DIAMETERS.) 
FIG. I. 

ACUTE EXUDATIVE NEPHRITIS. 
Convoluted tubules, filled with the exudate of fibrin, red bloodxells and leucocytes. 
b. Exudate in stroma. 




a. 



(MAGNIFIED 450 DIAMETERS.) 
FIG. 2. 

ACUTE EXUDATIVE NEPHRITIS. 
Glomerulus. The epithelium covering the capillary tuft is swollen and opaque. 



b. Convoluted tubules, filled with exudate, 
flattened epithelium. 



c. Tubule, with 



ACUTE PARENCHYMATOUS NEPHRITIS. 57 

of acute parenchymatous nephritis is described by Dela- 
field as acute exudative nephritis. There is no con- 
nective tissue change in the stroma. The kidney is in- 
creased in size. The cortex is thickened and pale. If 
there has been a considerable exudation of pus cells, this 
may be evident by whitish foci of the exudate in the 
cortex. The surfaces are smooth, and the capsules 
non-adherent. 

The epithelium of the convoluted tubules may be 
flattened, and the tubules dilated, or the epithelium 
may be swollen and necrotic, and in some places de- 
tached from the walls. 

The tubules may be empty, or they may contain 
the detached epithelium, hyaline material, and masses 
of debris ; probably portions of the necrotic cells. If 
the exudation has been severe, they contain fibrin, 
pus, and in some cases red blood-cells. The straight 
tubes, in addition to the exudate, may contain hyalin, 
granular and epithelial casts. 

In the glomeruli the epithelium is swollen, some- 
times so much so that the cells resemble those lining 
the tubes, and contain the same exudate. The cells 
of the capillary tufts are swollen and the normal 
aspect, which shows the convolutions of the capil- 
laries, is changed to a more or less inordinate mass 
of swollen epithelium. 

Although there is no connective tissue change in 
this form of nephritis, there may be an exudation 
of serum, leucocytes, and red blood-cells into the 
stroma. 



58 ACUTE PARENCHYMATOUS NEPHRITIS. 

The inflammatory process, as a rule, is not dif- 
fused throughout the whole organ, but appears in 
foci of varying size, some portions of the kidney 
remaining apparently normal. 

If the patient recovers, the inflammatory product 
is absorbed and the kidney returns to its normal 
condition. 

Acute productive nephritis. In this form of nephritis 
there is, in addition to the exudative form, a new growth 
of connective tissue and permanent changes in the 
glomeruli. 

In the more recent cases, the surfaces are smooth, 
but in those where the inflammatory process is more 
advanced the surfaces may be roughened and the 
capsules adherent. 

The cortex may be pale and thickened, or it may 
be mottled red and yellow. The color may, how- 
ever, be unchanged. The cortex is hypersemic and 
dark, and the pelvis is, as a rule, deeply congested. 

The growth of new connective tissue takes place in 
wedge-shaped portions of the kidney; corresponding to 
the territory supplied by an artery. These affected 
areas may be concrete and discernible, or two or 
more may merge together and render the changed 
portion more or less diffuse. 

The epithelium of the convoluted tubules may be 
flattened, or the cells may be swollen, necrotic and 
detached. The tubes themselves contain fibrin, pus, 
and some of the necrosed cells. As a rule, the 
tubules, where the cells are flattened, do not contain 



PLATE III. 




(MAGNIFIED 450 DIAMETERS.) 

ACUTE PRODUCTIVE NEPHRITIS. 

Capillary tuft. b. Hyperplasia of cells lining glomerulus, c. Connective tissue growth 
in the stroma, d. Tubules, with necrotic epithelium. 




(MAGNIFIED 450 DIAMETERS.) 

ACUTE PRODUCTIVE NEPHRITIS. 

a. Convoluted tubules, with necrosis of epithelium, b. New connective tissue growth. 
c. Detached epithelium. 



ACUTE PARENCHYMATOUS NEPHRITIS. 59 

as much exudate as those where the lining cells are 
swollen and necrotic. 

In the portion of the kidney where there is con- 
nective tissue growth, some of the tubules may be 
atrophied. 

The straight tubes may contain hyalin, granular 
and epithelial casts. 

In some of the glomeruli there is only a swelling 
and breaking down of the lining epithelium. In 
others there is a marked hyperplasia of the capsule 
cells, sometimes to such an extent as to severely en- 
croach upon the capillary tuft. These proliferated 
cells undergo fibrous degeneration. 

The cells of the capillary tufts are swollen and 
opaque. 

Clinical History. — The severity of the attack 
varies from one so slight that it often passes un- 
noticed, or is only accidentally discovered by urinary 
analysis, to one where the inflammation is so intense 
as to quickly overpower the system and cause death 
in a short time. 

The exudative variety is usually more intense and 
acute in form, although in some cases the productive 
variety is equally acute and cannot by the symptoms 
be differentiated from the exudative. Productive 
parenchymatous nephritis is usually sub-acute in charac- 
ter. The acute parenchymatous nephritis accompany- 
ing scarlet fever, that which develops during an 
attack of diphtheria and in pregnancy are usually of 
the productive variety, and the prognosis is conse- 



60 ACUTE PARENCHYMATOUS NEPHRITIS. 

quently more grave, death frequently resulting. Some 
recover, as is the rule with exudative variety, but 
more often complete recovery does not take place, 
although at the time the patient may seem to be restored 
to health. At greater or less intervals repeated at- 
tacks occur until finally the condition passes into the 
chronic form. 

The exudative variety of acute parenchymatous 
nephritis is the form which usually develops during the 
attacks of the other infectious diseases, etc., and in 
many of those occuring in scarlet fever, diphtheria 
and pregnancy. They are sometimes fatal, but the 
majority run a rapid course of one or two months 
and entirely recover. 

In most cases of acute parenchymatous nephritis 
the cardinal diagnostic points are well marked — i. e., 
scanty high-colored urine, with increased specific 
gravity, containing an abundance of albumen, blood, 
epithelial casts, epithelia and blood corpuscles, rapidly 
developing dropsy, both general and local, nausea, 
vomiting, headache, muscular twitching, convulsions, 
pain in the back, possibly epistaxis, heart impulse 
increased or diminished, high arterial tension, etc., give 
a picture so clear that it cannot be easily misunder- 
stood. The disease may commence with a distinct 
chill, followed by fever, the temperature rarely rising 
above 101° F. This is the rule when the nephritis is 
the result of exposure to cold or dampness. When, 
however, it occurs in the course of, or follows some 
other morbid condition, the fever may be due largely 



Ai JUTE PARENCHYMATOUS NEPHRITIS. 6 I 

to the original cause. Fever may sometimes be ab- 
sent, Pain of a dull, aching character, referred to the 
small of the back and extending down the course of 
the ureters, is a frequent symptom. When the disease 
has been caused by exposure, the pain is not so 
marked as in the other varieties, and is often absent. 
Nausea, vomiting and headache frequently announce 
the commencement of an acute nephritis, especially 
when the disease occurs as the consequence of scarlet 
fever and other infectious diseases. The vomiting is 
sometimes persistent and troublesome, but fortunately 
quickly disappears. Anaemia appears early, pro- 
ducing the characteristic waxy appearance. Dropsy 
and scanty urine are usually the earliest symptoms 
noticed. The dropsical condition first appears under 
the eyelids, and rapidly extends all over the 
body, involving not only the lower extremities and 
scrotum, but also the serous cavities. It may also 
lead to the more serious oedema of the lungs. These 
dropsical accumulations follow no special course of 
development, and, therefore, vary greatly in different 
cases ; in some cases the anasarca is so slight as 
to be scarcely noticeable. The amount of dropsical 
effusion often bears no relation to the intensity of the 
renal involvement. As convalescence is established, 
the dropsical effusion slowly disappears, though some- 
times it does so rapidly, accompanied by watery stools 
and polyuria. The urine usually bears a special re- 
lation to the dropsical condition, and the degree of 
nephritic inflammation. Micturition is increased in 



62 ACUTE PARENCHYMATOUS NEPHRITIS. 

frequency, though there may be complete anuria. Many 
cases are recorded where suppression of the urine 
persisted for days and was followed by recovery. Opinion 
varies as to the cause of anuria. The urine, however, 
is usually scanty, smoky, reddish or pink from the 
admixture of blood and contains an abundance of 
albumen. In some cases it may be a few days before 
its presence can be clearly demonstrated; it is 
always present at some time or other in the exudative 
variety, and when it once appears, it persists until the 
case is cured or death takes place. It may disappear 
in the productive form of the disease, or become quies- 
cent, to reappear when the exacerbation shows itself 
apparently as a new invasion. The chlorides are 
absent, the phosphates diminished and uric acid and 
the pigments are increased. The quantity of urea 
is diminished, the specific gravity is high, and varies 
from 1025 to 1030. The reaction is always acid. 
The sediment is usually abundant and contains 
blood, hyalin, and granular casts, red and white 
blood corpuscles, epithelia both from the convoluted 
and straight tubules and pelvis of the kidney, with 
crystals of uric acid, urates, oxalates, etc. As re- 
covery takes place the specific gravity is usually 
lowered, and may fall as low as 1010 with polyuria, 
which, however, soon disappears and is followed by 
the establishment of the normal urinary secretion. 

The pulse is hard, tense, and increased in frequency. 
The tension of the arterial system is always marked, 
and, as a consequence, dilatation of the heart some- 



ACUTE PARENCHYMATOUS NEPHRITIS. 63 

times rapidly occurs (in from 2 to 4 days) ; com- 
pensatory hypertrophy is frequent. These may be 
distinguished by their physical signs during life. 
When compensatory hypertrophy does not occur the 
dilatation often gives rise to dyspnoea, even when pul- 
monary oedema is absent. They sometimes cause 
sudden death. 

Uraemic symptoms and complications are announced 
by the headache, stupor, jactitations, convulsions, etc., 
which may come on insidiously. This is especially 
true in ursemic dyspnoea, a condition from which the 
patient rarely recovers. The ursemic symptoms may 
appear when the urine is copious and free from blood 
and casts and with only a small amount of albumen, as 
well as when the urine is scanty in amount and con- 
tains an abundance of albumen. Amaurosis is fre- 
quently present. Derangements of the alimentary 
tract are often noticed. The duration of the disease 
varies from two to several weeks, and in some cases 
it is months before recovery is complete and albumen 
and casts have ceased to appear in the urine. As reso- 
lution occurs the skin which was dry and hot becomes 
moist, the urine is paler and more copious, the dropsy 
disappears slowly — though it may do so rapidly by 
critical discharges from the bowels and kidneys — and 
the constituents of the urine soon become normal. 

In acute parenchymatous nephritis from non-infectious 
bacteria there is moderate fever, and the urine con- 
tains a small quantity of albumen, a few leucocytes, and 
red blood corpuscles with a large number of bacteria. 



64 ACUTE PARENCHYMATOUS NEPHRITIS. 

These cases are usually mild in character and last from 
one to six weeks. 

The malarial form may be of the exudative or pro- 
ductive variety, and is characterized by the large 
quantity of blood in the urine. Recurrent attacks 
are apt to be frequent unless the patient is at once 
removed from the malarial region. 

In diphtheritic nephritis the dropsy is never marked, 
cardiac hypertrophy does not develop, the disease 
usually running a rapid course terminating in re- 
covery. If it is of the exudative variety the urine 
rarely contains blood casts or corpuscles and the specific 
gravity is never high. 

As a complication or sequela of typhoid fever it is 
usually accompanied by catarrh of the urinary tract, 
which makes its appearance during the second week of 
the disease. Bodin, in N. Y. Medical Journal, August 
11th, 1894, describes three varieties. 1st, one in which 
albumen appears more or less abundantly in the urine, 
with suppression of urine, oedema and symptoms of acute 
uraemia, terminating fatally with coma or convulsions. 
2nd, a variety less violent, but always grave; urine 
diminished in quantity, albuminous, and containing 
blood. 3rd, the most frequent; characterized by aggra- 
vation of the general condition, dryness of the tongue, 
pain in the loins, headache, and the appearance of a 
small quantity of albumen in the urine. The urine in 
this variety of acute parenchymatous nephritis fre- 
quently contains micrococci, with or without the 
bacillus of Eberth, streptococci and staphylococci. It 



ACUTE PARENCHYMATOUS NEPHRITIS. 65 

is believed that these bacteria enter into the blood 
from the intestines through intestinal ulceration. 

In relapsing fever there is an abundance of des- 
quamated renal epithelia in the urine. When the 
disease occurs as the result of exposure to cold and 
dampness, it is usually ushered in by a chill, followed 
by high fever, pain in the back and rapidly developing 
dropsy. When from scarlet fever it usually makes its 
appearance between the second and sixth week of the 
disease, and is announced by nausea, vomiting, dimin- 
ished secretion of urine, and headache. When of toxic 
origin, it is usually accompanied by frequent micturition, 
bloody urine, and the general symptoms of an acute 
cystitis. 

There is a form of acute exudative nephritis which 
deserves special notice, and which is characterized 
by the presence in the urine, in addition to the 
usual elements found in nephritis, of a large quantity 
of pus cells, which do not occur as the result of an 
associated cystitis but are due to the excessive violence 
of the nephritic inflammation. It occurs in some of the 
infectious diseases both in childhood and adult life. 
The symptoms appear suddenly and with great inten- 
sity. Restlessness, delirium, coma and convulsions are 
marked, dropsy is absent or slight, prostration 
appears early and progresses rapidly, followed by a 
typhoid state and death. There are but few recoveries. 
This form is believed to be due to some unknown 
micro-organism. 

Prognosis. — The prognosis in acute exudative ne- 



66 ACUTE PARENCHYMATOUS NEPHRITIS. 

pliritis is far better than in acute productive nephritis 
In the acute exudative variety, when the cerebral 
symptoms are not prominent and the disease pursues 
the ordinary course, a favorable termination may be 
looked for. When grave cerebral manifestations are 
present (headache, restlessness, delirium, coma, and con- 
vulsions), the prognosis must be guarded, though it is 
sometimes favorable even in the most alarming cases; 
much, however, depends upon the exciting cause : 
when, on account of the severity of the inflammation, 
pus cells appear in the urine in large numbers, the 
prognosis is very unfavorable. When from intermit- 
tent fever, exposure to cold or from diphtheria, the 
prognosis is favorable. When of the acute productive 
variety, the prognosis is very unfavorable, even when 
the patient does not present serious symptoms. Either 
death will occur in a few days, weeks or months, or 
after numerous exacerbations and apparent recoveries, 
the patient finally passes into a chronic and in- 
curable state. In the post-scarlatinal form, the majority 
of deaths occur either from ursemic complications 
or from heart failure due to acute cardiac dilatation. 
Sometimes, in cases where there are no specially 
severe symptoms, sudden death occurs from this 
cause. Uraemia is not necessarily fatal. Pulmonary 
oedema, oedema glottidis, hydro-thorax, hydro-pericar- 
dium, ascites, and the occurrence of local inflammations 
in the pleura, lungs, or peritoneum are serious compli- 
cations and liable to cause death. 

Anuria, when persistent, generally indicates a fatal 



A( TTK PAKENCHYMATOUS NEPHRITIS. 6j 

termination, though it sometimes continues for days 
without causing unfavorable symptoms. The danger 
in acute nephritis depends upon the impairment of 
the excretory power of the kidneys and the consequent 
retention of water and nitrogenous substances in the 
system which should have been eliminated. 

Treatment. — In the early stage of acute exudative 
nephritis, Aconite, Belladonna, or Veratrum viride will 
be the drugs most frequently indicated, to be followed 
by Cantharides, Rhus tox, Apis, Helleborus niger, or 
Apocynum cannabium. If of the productive variety, 
Mercurius corrosivus, Arsenicum or Plumbum car- 
bonic urn. Ursemic symptoms and convulsions will call 
for Cuprum arsenite, Cicuta virosa, Stramonium, 
Cannabis Indicus, Carbolic acid, Ammonium car- 
bonicum, Hyoscyamus, etc. 

Aconitum na/pellus. Acute nephritis from cold or 
secondary to scarlet fever, with rapid development of 
anasarca, high fever, restlessness, with soreness in the 
lumbar region. The pulse may be small and tense, with 
general feeling of anxiety, irritable stomach, surface 
of the body cool ; the patient starts from sleep in agony 
with cold sweat on forehead and limbs. 

Apis mellifica. Acute nephritis complicating scarlet 
fever or pregnancy. The dropsical conditions develop 
.rapidly ; the cedematous parts have a waxy hue. There 
is no thirst, limbs and back ache. Mental con- 
dition dull ; tonic and clonic spasms. All symptoms 
are worse the latter part of the night, and are relieved 
when sitting erect. 



68 ACUTE PARENCHYMATOUS NEPHRITIS. 

Apocynum cannabinum. Causes increased blood pres- 
sure and congestion of the kidneys. It has been called 
the vegetable trocar — from the rapidity with which 
general dropsies disappear when it is administered in 
appreciable doses — i. e., two drop doses of the tincture 
in a dram of water every hour, or better yet, one half 
dram doses of a fresh infusion. This remedy is indic- 
ated in acute nephritis with scanty, dark colored urine. 
There is great thirst, but water nauseates; oppression 
in the epigastrium and chest; pulse irregular, intermittent 
and feeble ; stupor, with constant automatic movements 
of one arm or leg. 

Arsenicum album. Is rarely indicated in the exud- 
ative variety, but is invaluable in the productive form of 
acute nephritis. When dropsical conditions are present, 
all symptoms are sub-acute, with progressive weakness, 
anxiety, restlessness, uraemia, and thirst for small quan- 
tities of fluid. Dyspnoea, either from cardiac weak- 
ness or oedema of the lungs, worse on lying down, 
especially recurring at or after midnight, and relieved by 
expectoration. Groodno says he obtains the best results 
from this remedy when he administers it in the form of 
Fowler's solution, drop doses every four to eight hours. 

Belladonna. Ac ate parenchymatous nephritis with 
flushed face, fever, and possibly delirium, char- 
acterized by tendency to strike and bite. This 
remedy relieves the congestion of the Malpighian 
capillaries but does not affect the secreting epithelium 
of the convoluted tubes. Large doses aggravate ; the 
medium potencies give rapid relief. 



ACUTE PARENCHYMATOUS NEPHRITIS. 69 

Cantharides. Following the antiphlogistics Aconite, 
Belladonna, Veratrum viride, etc., this becomes one of 
the most potent remedies, especially in the nephritis of 
scarlet fever and diphtheria. Dr. Dessau, Med. 
Times, 1895, quotes Prof. Cornil, London Practitioner, 
Vol. 27, P. 110, who says: "When the kidney of 
1 dogs and rabbits, poisoned with Cantharides, pro- 
' duced a nephritis it was impossible to distinguish it 
' from a condition of the kidney found in children 
' dying from the nephritis of scarlet fever or 
1 diphtheria. These observations will be quoted in 
' full, as they give perfect indications for the remedy 
'in acute parenchymatous nephritis. He observed 
{ intense congestion affecting the glomeruli, increased 
'tension of the blood in the vessels, the passage 
i through their walls of its liquid constituents, of 
1 serum carrying granules along with it, and some red 
1 and white blood corpuscles which accumulated in 
' large numbers in the glomerulus. At a, later stage 
' the inflammation shows itself in the straight and 
' convoluted tubes by multiplication of the cells and 
' modification of their form and migration of leu- 
1 cocytes." Pain in the region of the kidneys, loins 
and abdomen, with constant desire to urinate. Burn- 
ing, stinging and tearing pains in the region of the 
kidneys, uraemia, delirium and coma, with high fever, 
and hard, frequent pulse. 

Cicata virosa. Is beneficial in ursemic conditions, 
characterized by the twitching of individual muscles. 
Cuprum arsenite. Goodno says: "For ursemic symp- 



JO ACUTE PARENCHYMATOUS NEPHRITIS. 

toms in acute nephritis, unless contra-indicated, I now 
administer this drug in the second or third decimal tritu- 
ration, in three-grain doses, repeated every half hour to 
two hours until the symptoms subside. The remedy 
possesses a most remarkable influence over ursemic 
convulsions. In quite a number of typical cases seen 
by him and others, its use has been followed, even 
in desperate cases, by the disappearance of the con- 
vulsions, improvement being usually apparent in 
from two to four hours." The experiments of the 
Central Homoeopathic Society of Germany show con- 
clusively that this remedy causes renal inflammation 
and degeneration of the epithelium of the tubules of 
the kidney, with scanty and albuminous urine. 

Helleborus niger is especially useful in post- 
scarlatinal nephritis with dropsy, scanty high-colored 
urine, with or without mental stupor from ursemic 
conditions. Five-drop doses of the tincture in water 
every two to four hours will act raj3idly in the sudden 
dropsies of acute nephritis. 

Mental torpor predominates, pupils dilated, the eyes 
do not react to light, and while the patient sees im- 
perfectly, he does not comprehend what he sees. 
Violent pains in the head — so severe as to cause con- 
stant change of position — dull pain in occipital region, 
worse on stooping; nausea, vomiting, absence of 
thirst; convulsions, with cold extremities; dropsical 
conditions, with frequent desire to urinate. 

Mercurius corrosivus is indicated in the productive 
form of nephritis. It causes inflammation of the kidneys, 



ACUTE PARENCHYMATOUS NEPHRITIS. J I 

acute congestion, or inflammation of the secreting 
portion. The urine is blackish, scanty, or completely 
suppressed, and contains albumen, blood corpuscles, 
and granular and fatty casts. The epithelial cells 
from the uriniferous tubules, are found to be in 
a state of fatty or granular degeneration. Groodno 
says the patient looks wretched, is anaemic, short of 
breath, the urine is highly albuminous, and mic- 
turition is frequent. It acts best after the dropsy has 
subsided somewhat, or is not a prominent feature. 
The third trituration has been found the most effi- 
cacious. 

Ulius toxicodendron. Groodno says: "After subsidence 
" of the initial hypersemia, I have found this medicine 
"useful in cases not marked by dropsy. In idiopathic 
"nephritis; in nephritis clearly attributable to exposure 
"to cold and damp, especially when brought on by 
"getting wet during a cold rain; in nephritis ushered 
"in by much pain in the back and general soreness 
"or aching, also in some cases following scarlatina 
"without these conditions." He advises the tincture 
in % drop doses hourly. 

Terebinth will be found especially useful in acute 
croupous nephritis from colds and malarial conditions. 
From its pathogenesis it is only indicated when blood 
is found in the urine. Its main influence is expended 
upon the Malpighian bodies. The urine is scanty, 
smoky, bloody or almost suppressed; dropsy may 
be absent. It is rarely indicated in cases where 
ursemic symptoms are present. 



72 ACUTE PARENCHYMATOUS NEPHRITIS. 

Veratrum viride is required for the congestion of 
the cerebral vessels, for the convulsions in the early 
stage and during the course of acute parenchymatous 
nephritis. When indicated by the increased arterial 
tension, high temperature, and thin, small pulse with 
troublesome vomiting, it quickly relieves the symptoms. 

In addition to the above, Cannabis Indicus, Plumbum 
carbonicum, Chelidonium, Colchicum, Sabina, Scilla, 
Veratrum album, Antimonium tartaricum, Bryonia alba, 
Nitric acid, Grlonoin, etc., may be required. For special 
and more complete indications see Chapter XL. 

While many cases could be prevented by the ob- 
servance of proper hygiene and care in the adminis- 
tration of certain irritating drugs, as Cantharides, 
Turpentine, etc., it is impossible to do so when it 
occurs as a complication of the infectious diseases 
or when of bacterial origin, except in protecting the 
patient from exposure, etc. 

In all cases apply warmth, but without producing 
sweating. The sick room must be kept at a tempera- 
ture of 72° to 74° F., and the exposure of the 
patient to draughts of air, even over the bed, 
should be carefully guarded against. The patient 
should remain in bed, between flannel sheets, clothed 
in flannel until all, or nearly all, the albumen has 
disappeared from the urine and the other symptoms 
have abated. In many cases the mere fact of the 
patient sitting up after the albumen has disappeared 
from the urine, has caused an exacerbation of the 
disease and a return of the albumen. 



ACUTE PARENCHYMATOUS NEPHRITIS. J 3 

Warm baths daily, at 100° to 105° F., lasting from 
five to fifteen minutes, followed by rest and quiet for 
one or two hours, or hot packs given by wrapping np 
the patient for one or two hours, in a flannel blanket 
wrung out of hot water, and repeated once or twice a 
day, are very necessary to remove dropsical effusions. 

In many of the more critical cases, hot air baths are 
indicated, and are of great service. Air heated by 
means of an alcohol lamp, placed at the side of the 
bed, is conducted between the blankets covering the 
patient through two lengths of stove-pipe with an 
elbow. The whole body should be daily sponged with 
tepid water, under the bed clothes, to assist diaphoresis 
and give comfort to the patient. Dry cups, from two to 
twelve in number, applied over the kidney region once 
or twice daily are sometimes useful in relieving the 
local congestion. Hot boric acid stupes, applied 
hourly, and covered with oiled silk, are often of great 
service. The bowels must receive proper attention; if 
constipation is present, the unloading of the venous capil- 
laries may be produced, and the abdominal circulation 
decidedly improved by drachm doses of Magnesia sul- 
phate every hour until eight doses have been given, or 
there is an evacuation. The better way, however, to re- 
lieve the constipation and the stagnation of the circula- 
tion is to flush the rectum daily with two to four quarts 
of hot water at a temperature of 102° to 105° F. 
In many cases a portion of the water is retained, 
absorbed and excreted by the kidneys. 

Milk is the classical food, not only because it 



74 ACUTE PARENCHYMATOUS NEPHRITIS. 

contains all the body -building principles, but be- 
cause it seems to possess a diuretic action. It can 
be varied to advantage witli Hudson's food, malted 
milk, buttermilk, kumyss, matzoon, and usually 
some animal broths. If ursemic symptoms should 
appear, nitrogenous food of every description must 
be avoided. Poland, Stafford, Clysmic, distilled, 
or any pure water, must be ingested in large quan- 
tities, in order to flush the kidneys, and at the 
same time remove the solid constituents from the 
blood. In the treatment of acute parenchymatous 
nephritis, it is important to increase the quantity of 
the watery and nitrogenous excretions from the kid- 
ney, which are usually greatly diminished, and which, 
if neglected, accumulate in the system, producing 
headache, convulsions, coma, and dropsical accu- 
mulations. Diuretics (per sej, while relieving some- 
times, as a rule increase the inflammation in the 
kidney, and do more harm than good. They are as 
harmful as cathartics in the very acute cases. In 
productive nephritis, Digitalis, Caffein, Strophan- 
tus, Diuretin, Acetate of Potash, Squilla, etc., 
may be used in appreciable doses as a make- 
shift, The hydragogue cathartics, Jalap, Elaterin, 
etc., sometimes give rapid results, but they cannot 
be continued, as they will eventually irritate the 
stomach and exhaust the patient. The arterial 
tension should at all times be carefully watched, 
and the timely administration of Aconite, Bella- 
donna, Glonoin, Amyl nitrate, Chloral hydrate, etc. 



ACUTE PARENCHYMATOUS NEPHRITIS. 75 

will often avert many of the more serious nervous 
symptoms. 

If convulsions occur, Chloroform by inhalation may 
be given for immediate relief, or rectal enemas contain- 
ing 10 to 20 grains of Chloral hydrate or 20 to 60 grains 
of Potassium bromide may be used. When heart failure 
is imminent, Digitalis, two or three drops of the fluid 
extract, or CarTein, Strophanthus, Spartein or Grlonoin 
will be required. When all forms of medicinal treat- 
ment fail and the cavities of the body are filled with 
dropsical fluid and the connective tissue is infiltrated 
to a marked degree, punctures into the dependent 
parts, or tapping of the cavities, with strict asepsis, 
will be found necessary. 

When the disease is of the exudative variety, as 
health returns, solid food may be gradually allowed 
and the usual duties of life resumed; but if it is 
believed to be of the productive type, the treatment 
must be continued for months, a warm, equable climate 
advised, with freedom from mental and physical fatigue, 
and some light outdoor employment or recreation. 

Dr. Reginald Harrison, Medical Record, Nov. 7, 
1896, records a number of apparent cures of acute 
productive nephritis by surgical methods. He gives 
two conditions in which surgical interference is indi- 
cated : 

1. Includes those instances in which the kidney 
complications are, from the onset, of the gravest char- 
acter and death is imminent. In these cases a fatal 
termination usually rapidly ensues, the duration of 



J 6 ACUTE PARENCHYMATOUS NEPHRITIS. 

life being largely determined by the degree of urinary 
suppression. 

2. A group of cases including those in which, after 
a limited time, the tendency, so far as the renal 
symptoms are concerned, is not in the direction of 
recovery. The amount of albumen does not decrease, 
tube casts, as well as other evidence of deterioration, 
are found in the urine, and the quantity of urine 
excreted is below what may be regarded as a fair 
average. Tenderness over the kidney on pressure is 
often complained of. 

That many cases of nephritis with high tension and 
subsequent structural deterioration must necessarily 
be attended by cardiac hypertrophy is obvious. Dimin- 
ished capacity of the excreting power of the kidneys 
can only be compensated for by increase in the force 
of the blood current. In the restoration of the function 
of the kidney we have the only safeguard against the 
development of this complication. In the surgical 
treatment of renal tension associated with albu- 
minuria, the kidney should be exposed by a moderate 
incision, so as to enable the operator to feel 
the organ distinctly, both in front and behind, 
aided, of course, by the hand of an assistant pressing 
the abdomen backwards from the front. If in con- 
junction with the presence of albumen in the urine, 
the kidney is found to be in a state of tension, three 
or four punctures should be made in the capsule in 
various directions. Should the organ be found to be 
in a higher state of tension, a longitudinal incision 



CHRONIC BRIGHT S DISEASE. J J 

into the cortex along the convex surface, one or two 
inches in length, should be made. 

If either of these methods has been adopted, a 
drainage tube should be inserted and the wound 
lightly packed with Iodoform gauze. The incision 
should be dressed in such a manner as to provide for 
the free escape of blood, urine, etc. 



CHAPTER X. 
Chronic Bright' s Disease. 

Chronic Blight's Disease will be described in 
three classes, which are sub -divided into . divisions or 
stages. 

1. Chronic Parenchymatous or Productive Nephritis 
with exudation. 

2. Interstitial or Productive Nephritis without exu- 
dation. 

3. Amyloid or Degenerative Infiltration of the Kid- 
ney. 



CHAPTER XL 
Chronic Parenchymatous Nephritis. 

Chronic Productive Nephritis with Exudation, 
Chronic Croupous or Tubal Nephritis, Chronic Glom- 
erulo -Nephritis, Chronic Desquamative Nephritis, etc. 

Delafield defines it as a chronic inflammation of the 
kidney attended with a growth of new connective 
tissue in the stroma, permanent changes in the glom- 
eruli, degeneration of the renal epithelium, with exu- 
dation from the blood vessels, and sometimes changes 
in the wall of the arteries. It is characterized by 
dropsy and albuminous urine, both well marked. 

Etiology. — It often follows acute productive pa- 
renchymatous nephritis, and is frequently caused by 
the malarial diseases, exposure to cold and damp, 
especially damp and unhealthy dwellings, grief, worry, 
etc. In some cases it comes on very insidiously, 
without apparent cause, especially in middle life, at 
which period it is most prevalent. It also occurs in 
certain blood dyscrasias, as rheumatism, gout, etc. 

Pathological Anatomy. — The kidneys in their 
gross appearance show a variety of forms. The most 
common is a large white kidney, with a white, thick 
cortex. The cortex, instead of being white, may be 
mottled red and white or red and yellow. 

The kidneys may be apparently normal, except 
that their cajmiles are adherent. 



PLATE IV 



a — 



V» * i * ***** .* f 



* 
« 



|r;^^ 






(MAGNIFIED 450 DIAMETERS.) 
FIG. I. 

CHRONIC PARENCHYMATOUS NEPHRITIS WITH EXUDATION. 

a. Capillary- tuft, with growth of epithelium, b. Hyperplasia of lining cells of glomerulus. 

c. Tubule, with partially destroyed epithelium, d. Tubules, containing exudate 

and detached epithelium, e. New connective tissue growth in stroma. 




(MAGNIFIED 450 DIAMETERS.) 
FIG. 2. 

CHRONIC PARENCHYMATOUS NEPHRITIS WITH EXUDATION. 

a. Convoluted tubules, with partially destroyed epithelium, containing exudate, b. Same as a, 

with epithelium detached, c. Tubule, dilated, and epithelium flattened, d. New 

connective tissue growth in stroma. 



CHRONIC PARENCHYMATOUS NEPHRITIS. Jg 

They may be small, with a white or red cortex. 

The surfaces may be smooth or nodular. The 
nodules may be large or fine, covering the whole 
surface. 

The capsules are not always adherent, even in some 
of the small contracted kidneys. 

The cortex is often irregularly thickened. In some 
places it may be thinned and in others so thickened 
as to obliterate a part or the whole of a pyramid. 

In the cortex the growth of connective tissue is 
abundant, in some portions to such an extent as to 
cause an atrophy of a large number of tubules. 

In other portions of the cortex the tubules may 
retain their normal size or may be dilated. 

The epithelium lining the tubes are in some places 
flattened and in others swollen. The tubes contain 
granular matter, fibrin, leucocytes and red blood cells, 
or they may be empty. 

In the glomeruli there may be a proliferation of 
the lining cells. This proliferation of cells subse- 
quently changes to connective tissue. 

There may be a hyperplasia of the cells covering 
the capillary tufts, often to such an extent as to fill 
the glomerulus. The glomeruli are sometimes en- 
larged, and at others atrophied. 

The arteries may undergo an inflammation involv- 
ing all three coats, or there may be a calcareous 
degeneration of the inner coat. 

Clinical History. — It has many symptoms in 
common with acute productive parenchymatous ne- 



80 CHRONIC PARENCHYMATOUS NEPHRITIS. 

phritis. Its course is chronic, varying from a few 
months to many years, and frequently follows an 
acute or sub-acute productive nephritis. In many 
cases, however, there are exacerbations, the result of 
excesses, cold, damp, pregnancy, rheumatism, etc. 

The dropsy, which varies from a slight oedema of 
the eyelids, feet and hands, to marked general anasarca, 
is one of the early — if not the earliest — symptoms 
noticed by the patient. This dropsical condition, like 
that in acute parenchymatous nephritis, does not 
depend upon the anatomical location for its special 
appearance but may, in different cases, appear in dif- 
ferent locations, and may even change its position. 
It may be so extensive as to cause sloughing of the 
parts. The effusion of blood-serum into the tissues 
is due to the same causes which allow of its exuda- 
tion with the urine. Semmola in 1881 demonstrated 
that blood-serum in chronic parenchymatous nephritis 
had a greater power of diffusion than in health or in the 
cirrhotic form of nephritis. 

The secoiid most noticeable and most marked con- 
stant symptoms is the anaemia (the accompanying 
pallor is sometimes described as the statesman's com- 
plexion). It is progressive, due to changes taking 
place in the blood; the red and white blood cor- 
puscles are gradually reduced in absolute and relative 
numbers, the fibrin remains about normal, while the 
amount of albumen fluctuates to a considerable degree, 
but is always much below the healthy average. At 
the same time the blood is charged with the nitrogenous 



CHRONIC PARENCHYMATOUS NEPHRITIS. 8 I 

products of alimentation, which the kidneys in their 
impaired condition have been unable to excrete. 
This condition of the blood plays an important 
part in producing the dyspnoea, nausea, indigestion, 
headache and prostration, which mark the disease. 
The emaciation, early in the disease, is not notice- 
able, as the condition of general anasarca obscures 
it to a great degree, while later, if a condition 
of atrophy of the kidney is developed, the 
oedeniatous condition will somewhat subside, and 
the emaciation in consequence becomes very 
apparent. 

Micturition is increased in frequency, though the 
quantity of urine voided during the day will usually be 
somewhat reduced. The specific gravity of the urine is 
lowered, generally it is about 1010, due to reduction in 
the percentage of urea; it may, however, be greatly 
increased. It is found that in those cases which 
run a rapid course, that the specific gravity is higher, 
1012-1020, than in the more chronic, when it is 
about 1001-1006. A low specific gravity indicates a 
large growth of connective tissue in the cortex of 
the kidney. The acidity of the urine is below the 
average, albumen is found in abundance, urea is 
diminished, uric acid is about normal, casts are 
numerous, the granular variety being considered char- 
acteristic of this form of kidney disease, although 
hyaline, waxy or fatty casts are sometimes found. 
The hyaline casts may be either large or small, and 
they, with the lighter colored granular casts, are 



82 CHRONIC PARENCHYMATOUS NEPHRITIS. 

found early in the disease, while later the majority 
are of the dark, granular, waxy or fatty varieties. 

The blood casts and those well covered by epith- 
elium are rarely met with in this form of Bright's 
disease unless an acute attack of nephritis has super- 
vened. The predominance of certain casts leads us 
to the diagnosis and the pathological condition of the 
kidneys. Whenever blood corpuscles, pus and epith- 
elial cells are found in the urine, it is evidence that 
an acute attack has been added to the chronic in- 
flammation of the kidney tissue. If atrophic changes 
take place in the latter stage of chronic parenchy- 
matous nephritis, the quantity of urine will be in- 
creased and its specific gravity relatively diminished. 
The heart is rarely affected, cardiac dilatation and 
hypertrophy are uncommon, and, if present, are not 
usually noticed during life. 

Cerebral hemorrhages and epistaxis are uncom- 
mon. Dyspnoea is frequent, it may be of ureemic 
origin, due to general anaemia or from dropsical 
accumulations. It may be continuous or transitory, 
coming on in attacks, especially at night or in the 
early morning, and is always worse when the patient 
assumes a recumbent position. Dyspnoea of nephritic 
origin is very frequent, when it is present and not due to 
disease of the lungs or heart, the urine should always 
be examined. 

Loss of sight sometimes occurs, due to albuminuric 
retinitis; it may be transient or permanent, both eyes 
are usually affected; it may somewhat improve, but 



CHRONIC PARENCHYMATOUS NEPHRITIS. 83 

complete recovery is rare. Headache is a common 
accompaniment; it may be confined to the fifth pair 
of nerves or appear as a migraine with nausea and 
vomiting. In all cases of this class where the cause 
of these symptoms cannot be found, it would be well 
to examine the urine. 

Eheumatic pains sometimes accompany the oedema 
of the muscles. They are usually dull but some- 
times shooting in character, and are not relieved or 
aggravated by motion or pressure. Pains in the 
regions of the kidneys are rare. Anaesthesia of 
the fingers, usually of the left hand, is sometimes 
noticed. Fever is never present unless an acute 
Bright's disease has been added to the chronic con- 
dition. Bronchial symptoms are always present in 
well-marked cases of chronic parenchymatous ne- 
phritis. Flatulent indigestion, vomiting and diarrhoea 
are frequent; the tongue is usually clean. Ursemic 
convulsions are rare. 

This form of Bright's disease is essentially 
that of middle life, rarely occurring after the fiftieth 
year. 

Diagnosis. — This is usually easy, especially when 
the generic symptoms are marked — i. e., extensive 
dropsy, with diminished quantity of the urine of low 
specific gravity, albuminuria, and an abundance of 
granular and fatty casts, together with the absence 
of distinct cardiac lesion. When contraction (atrophy) 
of the kidney has developed, causing increased cardiac 
action and consequent hypertrophy, it is sometimes 



84 CHRONIC PARENCHYMATOUS NEPHRITIS. 

impossible to differentiate this condition from the in- 
terstitial variety of chronic Bright's disease. 

Prognosis. — Unfavorable ; complete recovery is rare. 
The younger the patient, the more favorable the 
prognosis. That some cases, even when of long stand- 
ing, terminate in recovery, there is not the slightest 
doubt, but everything depends on the amount of 
kidney tissue involved, on the treatment and hygiene 
advised, and the way it is followed. When of syph- 
ilitic origin, the prognosis is favorable ; when from 
scrofula, it is unfavorable. When the relative quantity 
of albumen is over 1 per cent, by weight, and the 
number of granular, waxy and fatty casts is large, 
the prognosis is unfavorable. It is more favorable 
when the hyaline casts predominate. 

Treatment. — Arsenicum acts well in the chronic ne- 
phritis caused by scarlet fever and malaria, and 'especially 
in the large, fatty variety. Great anxiety is always 
present, with great despair, sure they are about to 
die ; rapid sinking of strength, and emaciation ; 
general oedema, beginning with puffiness of the eyes 
and extremities ; palpitation of the heart, cardiac 
dyspnoea, dyspnoea from oedema of the lungs, in- 
creased by lying down, especially recurring at mid- 
night ; skin feels cool, while they complain of thirst; 
water irritates the stomach, and causes vomiting. — 
All symptoms relieved by warmth. 

Cantliarides is useful in the early stage of chronic 
nephritis — relieving the headache, delirium, coma, etc. 
The urine is scanty, dark, and contains albumen, 



CHRONIC PARENCHYMATOUS NEPHRITIS. 85 

epithelia and casts from the tubiili-uriiiiferi. Mental 
stupor : drawing, tearing pains in region of the kid- 
ney ; lumbar region sensitive to touch; thirst, fluids 
do not affect the stomach, but they increase the pain 
in bladder and frequency of urination. 

Ferrum muriaticum will be indicated in proportion as 
the hepatic, digestive and assimilative functions are 
normal, and the albuminous process is remote from 
or independent of recent congestion, debility, with pale 
face that flushes easily, is marked; feeble action of 
the heart, occasionally losing a beat, together with 
pain in lumbar region, relieved by walking, aggra- 
vated by sitting. 

Kali muriaticum. Goodno reports excellent results 
with this remedy in Bright's disease, with pro- 
gressive aneemia and prostration. The patient is pale, 
breathless, with cardiac palpitation, urine scanty, high 
colored and albuminous. 

Mercurius corrosivus. General oedema of the body. 
Earthy pallor of the skin ; anorexia ; nausea, with 
weakness, and tenderness in the epigastric region ; pulse 
quick and feeble, great weakness and prostration, rest- 
lessness of the limbs, must change position frequently ; 
perspiration on slight exertion ; coma and convulsions. 
All symptoms worse at night and after sleep. 

Nitric acid. Great weakness, especially in the 
morning. Bright's disease, with gastric disturbances. 

Nux vomica. Bright's disease, with digestive dis- 
turbances ; patient irritable, morose, desires to be 
alone ; symptoms relieved by keeping quiet. 



86 CHRONIC PARENCHYMATOUS NEPHRITIS. 

Phosphorus is invaluable in the stage of fatty de- 
generation when fatty casts appear in the urine, fre- 
quently associated with a weak, empty feeling in the 
whole abdomen ; weakness of memory, etc. 

For the acute exacerbations, the remedies already 
given under acute parenchymatous nephritis must be 
consulted. For other remedies see Chapter XL. 

Hygiene is of the utmost importance. The body 
should at all times be warmly clothed with woolen 
or silken under-garments, warm but light in weight, 
and sufficient to prevent sudden chilling of the surface 
from rapid atmospheric changes. The patients need 
not be confined to their beds, though it has been 
demonstrated repeatedly that the albumen diminishes, 
and casts in the urine become less numerous, when 
from any cause nephritic cases are compelled to 
remain in bed. When possible removal to a warm 
equable climate is to be recommended where moderate 
outdoor exercise can be allowed without endangering 
their health. When this is impossible, the patient 
should remain indoors in inclement weather. Moder- 
ate exercise of body and mind should be en- 
couraged, and regular and sufficient sleep taken, but 
excesses of all kinds must be avoided. 

A strict milk diet is frequently of great benefit, 
though few will follow it for any length of time. 
Germain See advises the ingestion of large quantities 
of milk, from two to four quarts daily; he says that 
albumen frequently disappears under this regimen, 
and does not return when a more generous diet is 



CHRONIC PARENCHYMATOUS NEPHRITIS. Sj 

allowed. The usual practice is to advise a moderate daily 
allowance of milk, with a mixed though somewhat 
selected diet. Hale White says an ordinary full diet, 
in his experience, does not increase the tendency to 
unemic symptoms. Highly-seasoned food, smoked 
meats and alcohol in all forms must be forbidden. 
We should, however, always remember that, in this form 
of chronic Bright's disease, the condition of the kidneys 
is such that their secreting power is impaired, and they 
cannot be expected to do their usual quota of work, 
consequently a diet which will produce the smallest 
amount of urea, sustain the strength of the patient, and 
at the same time build tissue, should be chosen. Phy- 
siology teaches us that the amount of urea secreted 
is always in proportion to the quantity of nitrogenous 
food ingested; it is, therefore, evident that this class 
of food should constitute only a small or very moder- 
ate proportion of the daily aliment. Experiments 
have proved that non-nitrogenous food reduces the 
daily quantity of urea secreted, and increases the 
quantity of w r atery elements, it should, consequently, be 
advocated in order to reduce the quantity of urea and 
increase the amount of water. A large portion of the 
residue of the carbo-hydrates are expelled by the 
bowels and the skin — they can, therefore, be allowed 
in generous quantities. 

Hirschfield allows as a typical daily diet in this 
disease, six ounces of meat, thirteen ounces of bread, 
a liberal allowance of vegetables and fruit, one and 
a half ounces of sugar, and five ounces of fat. When 



55 CHRONIC PARENCHYMATOUS NEPHRITIS. 

the urine becomes scanty and high-colored, with more 
or less sediment, an increase in the quantity of 
water ingested will be of positive benefit, not only by 
increasing the quantity of urine, but it also washes 
out the secreting portion of the kidney. The waters 
usually recommended are Poland, Stafford, Waukesha, 
Clysmic, Hygeia, or any other pure or distilled water. In 
some cases saline waters will be required. The drop- 
sical condition may frequently be relieved by the ap- 
propriate remedy, but the hot air bath or pack are 
sometimes required. A warm bath at bed-time, be- 
ginning at a temperature agreeable to the patient, 
gradually brought up to 105° F., and continued from 
ten to twenty minutes, causes a diminution of the 
dropsical accumulations, and in a few hours increases 
the flow of urine. 

Morning sponge-baths, followed by general friction, 
are beneficial. Acute exacerbations are to be treated 
on the principles advised for acute parenchymatous 
nephritis. 

The condition of the heart, pulse and respiration 
deserve special attention. Whenever the pulse indicates 
increased arterial tension and it cannot be relieved by 
the selected remedy, we can on physiological grounds 
prescribe Nitro-glycerin, Chloral hydrate, Morphia, or 
Potassium iodide. If this condition is neglected or 
passes unnoticed, vomiting, headache, dyspnoea and 
convulsions will soon appear. The administration 
of Opium is admissable only when tension of the 
arterial system is present. Should the dropsical con- 



CHRONIC PARENCHYMATOUS NEPHRITIS. 89 

dition persist in spite of treatment, it may be neces- 
sary to give from one to four teaspoonfnls of the Infusion 
of Digitalis, freshly prepared from English leaves, 
every three or four hours: two-drop doses of the tinc- 
ture of Apocynum cannabinum every hour, or prefer- 
ably, a teaspoonful of the infusion of the fresh root. 
Pilocarpin has sometimes been of benefit, but it is 
decidedly contra-indicated where heart weakness to 
any degree is present. 

Large dropsical accumulations may require removal 
with the aspirator, or by scarification, under strict 
asepsis, of the cellular tissue in the most dependent 
portions of the body. 

Dyspnoea, caused either by arterial tension or drop- 
sical accumulations, is usually amenable to drug treat- 
ment. 



CHAPTER XII. 
Interstitial Nephritis. 

Renal Cirrhosis, Renal Sclerosis, Granular Atrophy, 
Red Granular Nephritis, Gouty Kidney, Chronic In- 
terstitial Nephritis, Contracted Kidney and Catarrhal 
Nephritis. 

Delafield defines it as a chronic inflammation of the 
kidney, attended with a new growth of connective 
tissue in the stroma, permanent changes in the stroma 
and glomeruli, degeneration of the renal epithelium 
and sometimes changes in the walls of the arteries. 

It has usually been considered pre-eminently an 
insidious and chronic disease, but later investigations 
demonstrate it to be in many cases of catarrhal origin 
and acute in nature. Virchow says: " There is first 
infiltration of the connective tissue, with cloudiness 
and swelling of the epithelium, followed by desqua- 
mation, the oedema being most marked between the 
cortical and pyramidal substances." 

Etiology. — Under the old pathology, the cause in 
the majority of cases was believed to be obscure or 
undiscoverable, but with the more perfect knowledge 
gained by careful investigation, it is apparent that 
cold, exposure and dampness play an important part 
in the cause of interstitial nephritis, the symptoms of 
which are so slight and trivial in the early stages 
that they frequently pass unnoticed. 



INTERSTITIAL NEPHRITIS. 9 I 

It was believed by many authors that indulgence in 
alcoholic beverages were the prime factor in the causation 
of this disease, but statistics prove beyond a question 
that interstitial nephritis occurs less frequently with 
those who take alcohol in moderation than with the 
strictly temperate : yet there are cases when the 
system has been saturated with alcohol, causing cir- 
rhosis of the liver, where the autopsy has given evi- 
dence of an associated contracted kidney. 

Climate has its effect ; the disease is essentially 
one of the temperate zone ; it is of infrequent oc- 
currence in the frigid, tropic or sub-tropic regions; 
this may be accounted for by the sudden atmospheric 
changes common to the temperate zone. 

Malarial poisoning is a very potent cause, not only 
on account of the congestion occurring during the 
paroxysm, and irritation caused by the excretion of 
the bile-acids, but because the attacks are repeated. 

Pregnancy has been the cause of many undoubted 
cases of acute and chronic interstitial nephritis ; the 
chronic condition being due frequently to the neglect 
of treatment during this critical period. 

Syphilis is especially a cause of interstitial nephritis, 
when its early treatment has been unsuccessful or 
neglected. In these cases the round cell formation in 
the interstitial connective tissue may be general. The 
disease has even developed in persons suffering from 
hereditary syphilis. 

Gout is a prime factor in the causation of inter- 
stitial nephritis. Continental authorities, however, re- 



9 2 INTERSTITIAL NEPHRITIS. 

serve the name of gouty kidney to those cases of 
interstitial nephritis in which there is a deposit of 
urate of soda in the pyramids of the kidney and 
along the tubules, giving on section a striated ap- 
pearance ; the microscopic change, however, is the 
same in all cases, barring this one point, and they 
both result in a condition which will not allow uric 
acid to be secreted by the kidneys, while urea, on 
the other hand, is secreted without difficulty. 

The ingestion of lead may also produce all the patho- 
logical changes of interstitial nephritis, and in cases 
of lead poisoning the kidney will usually be found 
involved. In many cases, though not suspected during 
life, in those who have worked in the Arts requiring 
lead, and death has been due to some other cause, 
if an autopsy was made, marked evidence of interstitial 
nephritis has frequently been found. In looking for lead 
as a cause of interstitial nephritis, we must not only search 
for it in professional painters, etc., but we must re- 
member that there is sufficient soluble lead in many 
of the drinking waters delivered through lead pipes, 
to produce the disease in those who are suscep- 
tible, especially when the water abounds in chlorides, 
nitrates, etc. 

Heredity acts as a cause, and cases have followed in 
families for generations ; perhaps it is due as much to 
hereditary weakness of the parts as to inherent family 
weakness, the nephritic disease being precipitated on 
the appearance of some of the exciting causes already 
mentioned. 



INTERSTITIAL NEPHRITIS. 93 

A.GE. — As gathered from statistics, the time of life in 
which this form of kidney disease is most common is be- 
tween the thirtieth and sixtieth year, though it may occur 
at any time ; a few cases have been recorded as having 
occurred before the fifth year. It may be considered 
a disease of manhood and advancing age. It occurs 
frequently in those weighed dowm by anxiety and 
business cares, and therefore the question might arise 
as to which of the last two causes mentioned were 
the most potent in the causation of this condition, 
especially when statistics show that the disease is 
much more common among the male than the female ; 
in the proportion of two to one. 

Cystitis, acute and chronic ; prostatitis, simple or 
hypertrophic; strictures of the urethra or ureter; cal- 
culi in the bladder, in the pelvis of the kidney, or 
in both, may, by their presence, cause congestion and 
inflammation, which, extending by contiguity of surface 
as well as by the interference with the urinary flow and 
genito-urinary circulation, will, in time, cause neph- 
ritic inflammation, usually of the interstitial variety. 
Valvular lesions of the heart, by change in the arterial 
tension, are also factors in the production of this disease. 
By some it is believed to be due to a general arterial 
tension with resulting renal sclerosis, while others main- 
tain that the renal obstruction is the original cause, and 
the general arterial tension follows it. Hypertrophy of 
the left ventricle always occurs in this variety of renal 
disease. 

Pathological Anatomy. — The kidneys are as a 



94 INTERSTITIAL NEPHRITIS. 

rule small, with roughened surfaces and adherent cap- 
sules. They may be normal in size and even large, 
but their surfaces are rough and capsules adherent. 
The cortex is thinned, and gray or red in color. 

The growth of connective tissue in the cortex is 
abundant and appears in irregular patches. 

In the cortex the tubes are atrophied or dilated. 
In some of the dense masses of connective tissue they 
may be completely obliterated. 

Their lining epithelium is flattened. Some of the 
tubes contain hyaline material, epithelium, fibrin and 
leucocytes ; some are greatly dilated, being almost cystic 
in their appearance. 

Many of the glomeruli are atrophied, some are 
larger than normal. There is a hyperplasia of their 
lining cells and the epithelium covering the capillary 
tufts. 

There is a generally diffuse connective tissue growth 
in the pyramidal portion. 

In some parts of the kidney the characteristic 
appearance of the organ may have given way com- 
pletely to the excessive connective tissue growth. 

Clinical History. — Of all inflammatory diseases of 
the kidneys none show such insidious development. 
The disease is rarely suspected by the patient or the 
physician until its presence is well marked or a ursemic 
convulsion or apoplectic seizure announces its presence. 
In the acute stage it is not often diagnosticated and the 
patient rarely calls upon his physician with this condition 
in mind, but usually to be relieved of some secondary 



PLATE V. 







If 



\A ' 

(MAGNIFIED 450 DIAMETERS.) 

CHRONIC INTERSTITIAL NEPHRITIS. 

a. Capillary tuft, and atrophied glomerulus. b. Atrophied tubules, with detached epithelium. 
c. Connective tissue growth. 



/ 



- 



W *f . - 




(MAGNIFIED 450 DIAMETERS.) 

CHRONIC INTERSTITIAL NEPHRITIS. 

a. Atrophied glomerulus, b. Faint remnant of capillary tuft. c. Connective tissue growth. 

d. Atrophied tubule, e. Dilated tubule, with flattened epithelium. 

/. Atrophied tubules, with detached epithelium. 



PLATE VI. 




SfS- -- 






**e? 



c ^^V&m 



■ 



«5» 

(MAGNIFIED 450 DIAMETERS.) 

CHRONIC INTERSTITIAL NEPHRITIS. 

a. Atrophied tubules, b. Connective tissue growth, c. Hyaline masses in tubules. 

a. Detatched epithelium, imbedded in hyaline material. 



^praifc 



a 




[MAGNIFIED 450 DIAMETERS.) 



CHRONIC INTERSTITIAL NEPHRITIS. 
a. Atrophied tubules, b. Connective tissue growth, c. Detached epithelium. 



PLATE VII. 




- 




»• 



•VI 



(MAGNIFIED .450 DIAMETERS ) 
FIG. I. 

CHRONIC INTERSTITIAL NEPHRITIS. 
a. Dilated tubules, b. Detached epithelium, c. Flattened epitheliur 
d. New growth of connective tissue in stroma. 



__ CL 




(MAGNIFIED 450 DIAMETERS.) 
FIG. 2. 

SUPPURATIVE NEPHRITIS. 

a. Tubules, with degenerated epithelium, b. Tubule, filled with pus. 

c. Stroma, infiltrated with pus. 



<& 



INTERSTITIAL NEPHRITIS. 95 

symptom, the result of cardiac hypertrophy, as palpitation 
of the heart, dyspnoea, etc. 

This variety of kidney disease is characterized, when 
well advanced, by its associated hypertrophy of the 
left ventricle of the heart, headache, temporary amaurosis, 
gastro-intestinal disturbances, and general debility. 

The disease may continue for years without specially 
lowering the general tone of the body; in fact, even when 
fully developed the patient may enjoy comparatively good 
health, the power of endurance, however, gradually 
wanes and general debility slowly asserts itself, with 
wasting of the muscular and adipose tissues which, early 
in the disease, may apparently hold its own. The com- 
plexion becomes sallow and anaemic, and headaches 
become frequent. For this reason in all cases of per- 
sistent headache which are not readily explained by 
other causes, rigid and frequently repeated examination 
of the urine should be made for evidences which might 
indicate an interstitial nephritis. The headaches are 
persistent and are often so severe as to almost drive the 
patient out of his mind, and are usually accompanied 
by dull, deep muscular pains referred to various parts 
of the body; sometimes confined to the back of one leg 
and therefore frequently incorrectly ascribed to sciatic 
rheumatism. As the disease advances, the gradual 
obstruction to the circulation through the kidneys from 
the progressive contraction of the kidney tissue and 
complicating arteritis, causes a gradual increase of 
the cardiac hypertrophy. The hypertrophy of the 
left ventricle has much to do with the causation of 



90 INTERSTITIAL NEPHRITIS. 

the general symptoms, as well as the condition of the 
urine. 

As the heart responds by increased hypertrophy to 
the calls made upon it by the damaged kidney, the head- 
aches from arterial tension become more continuous and 
the mental symptoms more pronounced. The patients 
become radically changed in disposition. 

The cardiac hypertrophy, however, prevents dropsical 
conditions, and ascites is consequently rare in interstitial 
nephritis. Even a slight swelling of the eyelids, feet or 
hands is rare, unless the heart becomes weakened from 
some other cause, as over-anxiety, over-work, etc., but 
when hypertrophy ceases to compensate and dilatation 
of the heart occurs, the case being about to terminate 
fatally, dyspnoea and dropsical conditions similar to 
those in chronic parenchymatous nephritis devekrp. 
Interstitial nephritis is frequently associated with endo- 
carditis and may remain undiscovered until marked 
changes have occurred in the valves, etc. 

As the disease develops the urine gradually becomes 
more abundant — pale, clear, or foamy, is acid in 
reaction; the specific gravity varies from 1000 to 
1016 or even 1025. The relative quantity of urea 
is diminished, but the total quantity for the day 
usually averages about normal; the ability to secrete 
uric acid is gradually lost, so that in the later stages no 
uric acid is eliminated by the kidneys. Casts are in- 
frequent or absent ; when found they are of the small 
hyaline or light granular varieties, with an occasional 
leucocyte or epithelial cell attached to them; the 



INTERSTITIAL NEPHRITIS. 97 

large hyaline casts are sometimes present. If, from any 
reason, an acute nephritis is engrafted upon the original 
disease, a few blood corpuscles may be found. Early in 
the disease the only evidence of interstitial nephritis may 
be a few epithelial cells from the convoluted tubes of 
Henle. Later on, as the heart weakens, the casts become 
more numerous and of greater variety, as occurs in the 
contracted kidney of chronic parenchymatous nephritis. 
In the early period of this disease albumen is rarely dis- 
covered in the urine, and later when found is transitory; 
frequently it is absent or undiscoverable for weeks or 
months by the most delicate tests; hence the necessity 
for careful and long-continued search in all suspected 
cases of interstitial nephritis before a positive-negative 
diagnosis is made. It is not uncommon for a case of well 
developed interstitial nephritis to terminate fatally 
without albumen having been discovered in the urine, 
even after the most careful chemical examination. The 
amount of albumen never exceeds one per cent, by 
weight. 

The urine is greatly increased in quantity, due to 
the increased arterial tension necessary to force the 
blood through the Malpighian bodies which remain 
intact, many being destroyed by the contraction of the 
newly formed tissue : with the increased secretion of 
urine there is an increased frequency of micturition, 
especially noticeable at night. The pulse is always 
hard, tense, full, and wiry. 

The cardiac hypertrophy is progressive and produces 
palpitation, causing much annoyance to the patient — it 



98 INTERSTITIAL NEPHRITIS. 

may pass unnoticed. As the disease advances, unless 
life is extinguished by some extraneous cause, dilatation 
finally occurs, and after a varied train of symptoms, some 
uraemic condition will cause a fatal termination. 

Hemorrhages into the brain, or from the nose, stomach, 
etc., are frequent in interstitial nephritis ; one in every 
sixteen die from cerebral hemorrhages, the reason of this 
pathological condition being the increased blood tension. 
About one-half of all cerebral hemorrhages are due 
to recognized or unrecognized interstitial nephritis, 
resulting from the weakened condition of the vessels 
and especially the development of small milliary 
aneurisms, which Charcot says are frequently devel- 
oped in interstitial nephritis, as well as to the dimin- 
ished or want of coagulability of the blood ; hemi- 
plegia, with or without aphasia, may be the first 
condition to call attention to the kidney lesion. 

Autopsies have not revealed any increased thicken- 
ing of the cranial bones. The effect upon the eye 
is very marked, not only in the albuminuric retinitis 
that is frequently noticed by the opthalinologist long 
before other rational symptoms can be discovered, 
but also by a temporary amaurosis which may appear 
and disappear from time to time without apparent 
physical lesions. Uraemic symptoms are very com- 
mon in this form of Bright's disease. 

Epileptiform seizures and muscular twitching occur ; 
convulsions may appear, also insanity, but whether 
caused by the nephritis or the mental condition is as 
yet unknown, in some cases, however, the mental 



INTERSTITIAL NEPHRITIS. 99 

aberration has bonne a special relation to the nephritic 
symptoms. Delirium, stupor or coma may develop 
rapidly or slowly. 

As the disease progresses dyspnoea appears, some- 
times as transitory attacks lasting for a few minutes 
or hours, and are liable to be produced by mental 
or physical fatigue or excitement, and to occur in the 
morning and pass off towards night; ursemic symp- 
toms gradually become more marked, and coma, convul- 
sions, etc., finally cause death. 

The sexual appetite progressively diminishes as the 
disease advances. Bronchitis and other chronic res- 
piratory diseases are common complications of inter- 
stitial nephritis. The most serious complication is 
pericarditis. 

Diagnosis. — It may be impossible, in the early 
stage of interstitial nephritis, to make a positive diag- 
nosis, but a careful and persistent examination of the 
urinary sediment, even if it is slight in amount, will 
usually reveal epithelial cells from the secreting parts 
of the kidneys, which are pathognomonic of com- 
mencing interstitial nephritis. There is but one layer 
of these cells, and when desquamated they are never 
replaced; their position afterwards being occupied by 
endothelium, which is rarely thrown off, and is conse- 
quently not found in the urinary deposit. The microscope 
must be our main dependence for the early recognition of 
this disease. In contracted kidney following paren- 
chymatous nephritis, there is an abundance of albumen, 
and casts are numerous ; dropsy is well marked ; 



IOO INTERSTITIAL NEPHRITIS. 

cardiac hypertrophy may or may not be present ; if it 
is, the urine will be abundant and the dropsy slight. 
In interstitial nephritis cardiac hypertrophy is marked ; 
casts are few in number, usually of the hyalin or light 
granular variety ; dropsy is absent ; urine abundant, 
and the albumen insignificant in amount. 

In the large white kidney, the urine daily secreted 
is less than normal ; the specific gravity is possibly 
increased; albumen is abundant, and the dropsy 
marked. There is no enlargement of the heart. 

Prognosis. — Unfavorable for recovery, favorable as 
regards the prolongation of life, provided the amount 
of tissue involved is limited; the progress of the disease 
is greatly dependent on the hygiene and mode of life. 
When compensatory hypertrophy gives place to dila- 
tation the end is not far off. 

Treatment. — Arsenicum is indicated in interstitial 
nephritis of malarial origin, or in the productive 
nephritis following scarlet fever, with hypertrophy of 
the left ventricle ; cardiac asthma, aggravated on lying 
down, the paroxysms occurring especially about mid- 
night ; tingling in the fingers, particularly of the left 
hand; restlessness, anxiety, thirst for small quantities 
of water, which may be immediately rejected ; rapid 
sinking of the vital forces. 

Aiirum muriaticum. Urine clear, copious, slightly 
albuminous, with few casts ; cardiac palpitation, press- 
ing pain or feeling of heat in the lumbar region, ex- 
tending to the bladder, and down the sides ; over- 
sensitiveness to pain ; hypochondriac, quarrelsome, 



INTERSTITIAL NEPHRITIS. IOI 

general weakness, with gastric and hepatic dis- 
turbances. 

Glonoin. Polyuria, urine of low specific gravity, 
violent heart action, great arterial tension, painless 
throbbing in all parts of the body, face bright red, 
puffy, cerebral hyprsemia, pain in head aggravated 
by motion, relieved by external pressure. This remedy 
has given great relief in arterial tension, ursemic head- 
aches and cardiac asthma ; it also reduces the quantity 
of urine secreted. 

Kali iodide. When due to syphilis this remedy 
acts well. The symptomatic indications are darting 
pains in the kidney region, burning pains in the lumbar 
region with difficulty in walking, urine clear and copious, 
especially at night, urea diminished. 

Lithium carbonicum and benzoicum have been of much 
benefit when the interstitial nephritis was of gouty 
origin. 

Mercarius didcis. This preparation of mercury seems 
especially adapted to interstitial nephritis, and is the 
variety that should be administered whenever mercury 
is indicated. 

Nitric acid. Interstitial nephritis with copious, pale 
urine of low specific gravity, and general symptoms 
of atonic gout. It is characterized by great weakness 
and prostration, especially in the morning, with pains 
of a pressing character in the lumbar region. 

Nux vomica. Interstitial nephritis with gastric dis- 
turbances. Polyuria, nausea, vomiting, and the mental 
characteristics of this remedy. 



102 INTERSTITIAL NEPHRITIS. 

Plumbum metalUcum. Marked tendency to iirsemic 
convulsions, uric acid diminished, clonic spasms of the 
muscles of the face and extremities, dropsy slight, urine 
slightly albuminous, mental depression, amaurosis, etc. 
For other remedies with their symptomatic indications, 
see Chapter XL. 

When the disease is early recognized — that is, be- 
fore marked interstitial contraction of the kidney 
tissue has taken place, and compensatory hypertrophy 
of the heart occurs, life can be prolonged, and pos- 
sibly a cure may result, but all depends upon the 
patient, the advice, and the manner in which it is 
followed. After contraction of the kidney tissue has 
taken place, palliation only with prolongation of life 
can be promised or reasonably looked for. In those 
cases which promise a cure, we must have first a 
good general constitution and family history to start 
with. If the patient is obliged to reside in the tem- 
perate regions, and is worried by the anxieties of 
active business life, or indulges in excessive manual 
labor, relief cannot consistently be looked for. A 
dry, equable climate is to be advised, and in many 
cases a sojourn in the southern climates during the 
winter months, so as to avoid as much as possible 
sudden atmospheric changes. If unable to make this 
change, and out-door exercise is allowed, when the 
weather is inclement the patient should be confined to 
the house, or possibly remain in bed. Experience has 
shown that in many cases albumen is reduced or 
entirely disappears from the urine when the patient 



INTERSTITIAL NEPHRITIS. IO3 

from any cause has been confined to his bed; hence 
the advisability of the patient keeping in bed for some 
days until the albumen disappears ; and if at any 
future time it returns the bed treatment shonld be 
repeated. 

Dry, hilly climates, when warm, are more favorable 
than mountainous and seaside resorts, bnt the mistaken 
idea of sending patients to health resorts in the last 
stages of any disease is nnadvisable and cruel in the 
extreme ; it removes the patient from his family, with 
the deprivation of the usual comforts of life, and 
substitutes an unsatisfactory and unpalatable dietary, 
with possibly poor hygiene, and would be sure to 
hasten the end they are trying to postpone. But 
when climatic changes are properly advised and adhered 
to, there is no donbt they have much influence in 
retarding the progress of the disease. 

The patient should wear proper and seasonable 
clothing; silk or woolen underclothing should be worn 
at all times. Hot air and steam baths are beneficial, 
but when the general cardiac tone is below the normal, 
they must not be used sufficiently to weaken the pa- 
tient. The hot wet pack is frequently of benefit, 
but cold baths and sea bathing must always be pro- 
hibited. Sponge baths, followed by brisk friction of the 
surface, twice a week, are to be recommended. Mental 
and physical fatigue, anxiety and worry increase the 
severity of the symptoms ; everything that increases 
the action of the heart must be avoided. The heart 
tone must be maintained at all times, yet it must not 



104 INTERSTITIAL NEPHRITIS. 

be over-stimulated or headache, cerebral hemorrhages, 
epistaxis, etc., will be the result. 

The diet must be nutritious, but not so nitrogenous as 
to increase the work of the already damaged kidney. 
The classical diet is undoubtedly milk in some form, 
as it also has the power of reducing the quantity of 
of albumen and increasing the quantity of urea secreted. 
Some thrive on a milk diet, while others are unable 
to take it for any length of time. When large quan- 
tities of milk are daily ingested, say two to four 
quarts, it can be varied somewhat by adding a little 
salt, flavoring it with some palatable extract, pep- 
tonized, or taken in the form of a milk lemonade after 
peptonizing, mixed with vichy or lime water, or as 
kumyss, matzoon, or even ice cream, etc. ; the in- 
gestion of the fatty foods must be encouraged. When 
the plain milk diet causes muscular fatigue, some 
require the addition of a little farinaceous food. When 
this occurs, or indications of its approach announce 
themselves, more animal food must be allowed. Those 
who cannot tolerate the milk diet sometimes do very 
well on animal broths, fish (salmon and lobsters ex- 
cepted), veal and lamb, chicken, fowls in general, game 
and vegetables ; eggs, as a rule, should be avoided, 
and sugars and starches restricted ; others do well on 
a general mixed diet, but after all, each case is an 
entity by itself. When headache, nausea, etc., an- 
nounce the approach of ursemic conditions, the animal 
food must be reduced. When animal diet is necessary, 
the white meat is less objectionable than the red. 



INTERSTITIAL NEPHRITIS. I 05 

If the interstitial nephritis is the result of syphilis, 
some of the anti-syphilitic remedies will be required, 
as Mercury, Potassium iodide, etc. ; if of a gouty origin, 
Colchicum may be indicated. The dyspnoea will re- 
quire Nitro-glycerine or Chloral hydrate to dilate the 
arteries and control the heart. 



CHAPTER XIII. 
Amyloid Nephritis. 

Lardaeeous or Waxy Kidney, Depurative Infiltration 
of the Kidney, etc. 

Etiology. — It is always dependent upon some con- 
stitutional disease, and its course will depend upon 
the original excitant. It is frequently the result of 
chronic suppuration and ulceration as in the third stage 
of phthisis pulmonalis; ulceration and necrosis of the 
bony tissue in Pott's disease; chronic ulcers of the leg 
and in the tertiary stage of syphilis. In syphilitic 
cases it usually exists as a waxy infiltration of a con- 
tracted kidney. When the disease arises from other 
than syphilitic causes, there is no associated renal 
contraction. This infiltration is due to some chemical 
change in the constituents of the blood, and it appears 
first as small deposits in the minute vessels of the 
kidneys and other organs. This disease develops most 
frequently between the twentieth and fiftieth year of 
life, and more often in the male than the female. 

Pathological Anatomy. — The lesions which exist 
in this form of nephritis are the same as those found 
in chronic parenchymatous nephritis with exudation. 

In addition, the walls of the capillaries in the tufts 
of the glomeruli undergo amyloid degeneration. The 
cells covering the capillaries are swollen and increased 
in number. 



AMYLOID NEPHRITIS. \OJ 

Clinical History. — Amyloid changes in the kidney 
develop simultaneously with like changes in the liver, 
spleen, intestines, thyroid gland, etc. ; its distinc- 
tive clinical history is somewhat marked. It rarely 
occurs alone, but is associated with parenchymatous 
and occasionally with interstitial nephritis. The 
disease develops slowly, the subject becomes ema- 
ciated, the mine gradually increases in quantity 
and sometimes reaches, in a well marked case, 
one hundred ounces per day; the specific gravity 
ranges from 1003 to 1012. Albumen is abun- 
dant, but in the early stage the quantity of albumen 
is small in amount, is not persistent, and the quan- 
tity of urine daily excreted may be about normal, 
occasionally a little below the average. The urinary 
sediment is small, and casts are infrequent; when 
present they are of the hyaline variety, with an occa- 
sional large waxy cast, which gives the characteristic 
reaction with iodine. Sometimes we may find red and 
white blood corpuscles. If a decided parenchymatous 
nephritis is associated with this condition, the quantity 
of urine excreted will be less and the casts will be 
more numerous and of greater variety. There are no 
associated cardiac lesions in this condition of the kid- 
ney, hence no hemorrhages, headaches, dyspnoea, etc. 

Dropsy is usually present. It is persistent and 
appears particularly in, or may be confined to the lower 
extremities and abdomen. The dropsy and the in- 
creased quantity of urine are characteristic of amyloid 
nephritis, and are usually accompanied by diarrhoea 



108 AMYLOID NEPHRITIS. 

which is intractable in character. Vomiting may also 
occur; ursemic symptoms are rare. The anaemia is 
due more to the general dyscrasia than to any special 
lesion of the kidney. 

Diagnosis. — When the disease is associated with, 
or engrafted upon, some other kidney disease, it is 
almost, if not qnite, impossible to make a positive 
diagnosis until the autopsy, and the lesion is confirmed 
by the characteristic chemical reaction of the tissues, 
bnt in uncomplicated cases the diagnosis depends upon 
the large amount of urine, its low specific gravity, 
the accompanying dropsy and diarrhoea, with the 
absence of cardiac hypertrophy and uraemic symptoms. 

Prognosis. — This disease being a sequela of, and 
dependent upon, other diseased conditions of the sys- 
tem, and showing itself in other organs at the same 
time, may be looked upon as progressively fatal, 
although many years may elapse before death occurs. 

Treatment. — Kali iodide will be required for amy- 
loid nephritis of specific origin, accompanied by 
darting pains in the renal region, or a feeling as if 
the back was being squeezed in a vise ; urine clear, 
copious, especially at night. 

Lycopodium is very frequently indicated. The char- 
acteristic digestive symptoms are usually marked, due 
to the amyloid involvement of the mucous membrane 
of the stomach and intestines. All symptoms are 
worse from 4 to 8 p. m. 

Nitric acid. Great weakness, pressing pains in 



AMYLOID NEPHRITIS. I 09 

lumbar region, gastric disturbances, fetid breath, and 
obstinate diarrhoea. 

Phosphoric acid. Mental indifference, pains in back, 
nutritive disturbances; also indicated for the hectic 
fever and evidences of suppuration in other parts of 
the body, with which this disease is so frequently 
accompanied. For other remedies, see Chapter XL. 

The general treatment will vary with the cause of 
the disease. A generous diet is always indicated. 



CHAPTER XIV. 
Cystic Degeneration of the Kidney. 

Etiology. — This condition may be congenital or 
acquired. Those belonging to the congenital variety 
rarely live to the end of their first year. Virchow 
considers this form due to imperforate uriniferous 
tubes. Many die in utero, though occasionally life is 
prolonged to advanced years. In adult life, it is fre- 
quently associated with chronic interstitial nephritis, 
sometimes it occurs without apparent cause, between 
the fortieth and sixtieth year, usually accompanied 
with similar change in the liver and bronzing of the 
skin. Cystic degeneration of the kidneys is divided 
into five varieties : first, cysts associated with chronic 
interstitial nephritis ; second, general cystic disease 
without associated nephritis ; third, simple, solitary 
cysts ; fourth, hydatids ; fifth, dermoid cysts. 

Pathological Anatomy. — In the congenital form 
both kidneys are very much enlarged, the left being 
usually considerably larger than the right. The whole 
organ is an unshapely, irregular mass of cysts, crowded 
together and separated by connective tissue. (See Plate.) 
In some places the interspace between the cysts is com- 
posed of renal tissue, which microscopically may appear 
normal or characteristic of a chronic interstitial nephritis. 
The cysts are made up of a fibrous capsule varying in 
thickness, lined with flat epithelium. They contain a 



PLATE VIII. 




CONGENITAL CVSTIC DEGENERATION OF THE KIDNEY. 



From a specimen in the museum of the Metropolitan Hospital, New York 
(Photograph one-third size.) 



CYSTIC DEGENERATION OF THE KIDNEY. I I I 

light yellow fluid, which contains urea and the salts 
normally found in the urine. 

The acquired form. — Occasionally in otherwise nor- 
mal kidneys are found cysts, varying in size from that 
of a pin-head to that of a large bean. They are found 
throughout the cortical portion, between the pyramids, 
or on the surface immediately beneath the capsule ; 
the circumference of the cyst bulging out and at 
times giving the kidney the appearance of being tabu- 
lated. The kidney tissue surrounding these cysts may 
be compressed, and some of the more approximate 
tubules obliterated. They have a thin connective tissue 
capsule, are lined with flattened epithelium, and con- 
tain a thin watery fluid. 

In the atrophied kidneys of chronic parenchymatous 
nephritis without exudation, some of the tubules are 
dilated to such an extent as to form cysts. These are 
seldom large, but may attain a size visible to the naked 
eye. 

Hydatids of the Kidney. — Generally the left kid- 
ney is affected. The cyst may grow between the 
organ and its capsule, or in the kidney tissue. They 
may undergo an inflammatory process, adhesions, and 
inflammation may follow, and the cyst break into the 
intestine or surrounding soft parts. They may de- 
generate into a calcareous mass, consisting of phosphate 
of lime, cholestrin and fat. 

Small hydatids may rupture spontaneously into the 
pelvis of the kidney, the contents being discharged by 
the urinary passages. 



I I 2 CYSTIC DEGENERATION OF THE KIDNEY. 

Clinical History. — This is obscure and in many 
cases, even when the autopsy shows marked cystic 
degeneration of the kidney, the condition has not been 
suspected during life. There is usually pain in the 
lumbar region, and haematuria is occasionally present. 
Arterial tension and cardiac hypertrophy are generally 
absent. Dropsical conditions sometimes appear, but 
they cannot be differentiated from those occurring in 
chronic interstitial nephritis. Occasionally on examina- 
tion of the renal region by palpation, the enlarged 
kidney can be discovered and sometimes differentiated. 
Death occurs in the same manner as in interstitial 
nephritis, from cerebral hemorrhage, suppression of 
the urine or uraemia, principally the latter. 

Hydatid cysts of the kidney are very rare in 
America, but are frequent in Iceland and Aus- 
tralia. About one-fifth of all hydatid cysts found in 
the human body occur in the kidney. They are of 
more frequent occurrence in the male than in the 
female, probably due to his more intimate association 
with his friend, the dog. The left kidney is more 
frequently involved than the right. 

Small hydatid cysts may rupture into the urinary 
tract and be discharged with the urine, without their 
existence having been suspected. In some cases they 
become so large that they interfere with the functions 
of the kidney and encroach upon the neighboring 
organs, and their discovery becomes proportionately 
easy. As a rule, hydatid cysts develop in the sub- 
stance of the kidney, but they may be situated be- 



CYSTIC DEGENERATION OF THE KIDNEY. I 1 3 

tween the capsule and parenchyma. It is said that they 
can be recognized by their characteristic fremitus on 
manipulation, but the proper way is to aspirate and 
examine the cystic fluid for the hooklets. It should, 
however, be remembered that the simple puncture of 
the sac for diagnostic purposes has resulted in death, 
due to the escape of the poisonous contents of the 
cyst into the puncture tract. Inflammation with adhe- 
sion sometimes occurs between the sac and a neigh- 
boring part, followed by rupture into some of the 
natural outlets of the body, and may terminate in 
recovery, or, opening into a closed cavity, cause death. 

Dermoid cysts of the kidney have never been 
demonstrated in a human being. 

Treatment. — For remedies, see interstitial nephritis 
and Chapter XL. If one kidney only is involved and 
a cystic condition can be positively diagnosticated, a 
nephrotomy, with proper drainage, may be made ; 
sometimes the size of the cyst may necessitate a 
partial or complete nephrectomy; otherwise the treat- 
ment must be on the same general principles advised for 
chronic interstitial nephritis. If the cyst is of a hydatid 
variety, either a nephrotomy and enucleation of the 
cyst, or a nephrectomy will be indicated. 



CHAPTER XV. 
Albuminuria or Eclampsia of Pregnancy. 

Etiology. — In the latter months of pregnancy, al- 
buminuria, convulsions, etc., sometimes occur, with 
serious after-effects, and not infrequently with fatal 
termination; this is true in primiparae, and especially 
in twin-pregnancy. The most severe manifestations 
show themselves during labor or immediately after- 
wards. In multiparas, the symptoms are less severe, 
but there is a greater tendency for the condition to 
terminate in a productive form of nephritis. 

Many explanations have been offered as to the cause 
of this condition ; all are apparently defective and 
none have been universally accepted. 

Pathological Anatomy. — There is no special and 
characteristic kidney lesion. It has developed when 
the kidneys were normal, when in a state of acute 
degeneration, acute parenchymatous nephritis of the 
exudative or productive varieties, in chronic parenchyma- 
tous or interstitial nephritis, and in cystic degeneration. 

Clinical History. — This disease may practically 
be divided into three varieties ; first, a small class 
where albumen may or may not have been present in 
the urine, and where from some unknown cause the 
urine becomes highly albuminous, greatly and suddenly 
reduced in quantity, even verging on suppression, with 
great deficiency in the quantity of urea excreted, together 



ALBUMINURIA OR ECLAMPSIA OF PREGNANCY. I I 5 

with marked cerebral symptoms, convulsions, stupor, 
coma, vomiting, deficient vision, headache, arterial ten- 
sion, rise in temperature, etc., all or a portion of these 
symptoms being present in a given case, which, if not 
quickly relieved, result in death. If the treatment is 
successful, the cerebral symptoms gradually subside and 
the urine returns to a normal condition. This form of 
puerperal albuminuria is most frequently met with in 
primiparse. Second, a class usually found in the mul- 
tiparee, where in the later stages of gestation, the urine 
becomes scanty and albuminous, accompanied by con- 
siderable anasarca. These usually go through labor 
safely, but the kidney lesion passes into a sub-acute 
productive nephritis, which becomes chronic. Third, a 
class characterized by a daily increased secretion of an 
albuminous urine, deficient in its percentage of nrea. 
General symptoms are frequently absent, and confinement 
may be passed without accident ; this condition fre- 
quently occurs in the multipara and usually subsides after 
confinement, or it may terminate in chronic nephritis. 
"When the urine contains serum albumen, the case 
generally ends fatally or terminates in chronic nephritis. 
When the albumen is largely paraglobulin, eclampsia may 
be expected ; in the more chronic cases, and when the 
condition is due to intra-abdominal pressure, the symp- 
toms quickly subside, as soon as the pressure is re- 
moved by delivery of the foetus. 

In the last two forms the prominent symptoms may 
extend over a period of weeks or months. In the 



I I 6 ALBUMINURIA OR ECLAMPSIA OF PREGNANCY. 

first the advent is sudden and often leads to the death 
of the foetus in utero, as well as of the patient. 

Treatment. — For symptomatic indications, see 
uraemia, acute and chronic nephritis, and Chapter 
XL. General treatment should be instituted as 
soon as the condition is discovered, especially if any 
symptoms of toxsemia or cerebral symptoms are 
present, i. e., headache, vertigo, nausea, vomiting, loss 
of sight or hearing, and especially dyspnoea. 

All modern authorities agree that in cases of preg- 
nancy with albuminuria and symptoms of toxaemia, 
emptying of the uterus is of vital importance. This 
can be accomplished in three ways : If the case is not 
urgent, after the parts are made perfectly aseptic, 
the cervical canal should be dilated with a steel 
dilator, then packed with sterilized gauze, and the 
vagina tamponed; the tampon should be removed in from 
24 to 36 hours. Previous to the sixth month, this 
may be repeated until the cervix is sufficiently softened 
to allow of curetting. Hemorrhage is sometimes severe, 
and, when profuse, a uterine tampon may be required. 
After the seventh month and the case is not too urgent, 
use a tampon for 24 hours and follow it with manual 
dilatation and delivery, with the usual after treatment. 
Other cases require manual dilatation within an hour 
to save the life of the mother, and still others, from 
deformity, may require Cesarean section. 

Edgar in the Medical Record, Dec. 26th, 1896, 
summarizes the accepted treatment of to-day as fol- 
lows: 



ALBUMINURIA OR ECLAMPSIA OF PREGNANCY. I I J 

" Prevention lias three indications : to reduce the 
amount of nitrogenous food to a minimum ; limit the 
production and absorption of toxic materials in the 
intestines and tissues of the body, and assist in their 
elimination by improving the action of (1) the bowels, 
(2) the kidneys, (3) the liver, (4) the skin, and (5) 
the lungs ; if necessary, remove the source of foetal 
metabolism and of peripheral irritation in the uterus 
by the emptying of that organ. 

" The reduction of the amount of nitrogenous food 
to a minimum, can best be fulfilled in an exclusive 
milk diet, to which, as the symptoms subside, can 
be added fish and white meats. He has found it not 
only safer, but less trying to the patient, to commence 
with an absolute milk diet, than to compromise and 
afterward be compelled to cut off all but the milk. 

" Elimination must be secured by an abundant 
supply of pure air and water, assisted by moderate 
exercise or light calisthenics or massage in certain 
instances. For the bowels he advocates daily doses 
of Colocynth and Aloes at bedtime, followed by a 
saline in the morning. For the liver an occasional 
dose of Calomel and Soda at bedtime, followed in the 
morning by one of the stronger sulphur waters, as 
Rubinat, Villacabras, or Birmenstorf. Increased di- 
uresis is secured by maximum doses of Grlonoin. The 
action of the skin is encouraged by encasing the 
body in wool or flannel underclothing, by massage, 
by the warm bath, hot bath, hot pack, or hot air 
bath, according to the urgency of the case. 



I I 8 ALBUMINURIA OR ECLAMPSIA OF PREGNANCY. 

" In instances of eliminative insufficiency he gives at 
bedtime twice weekly, or more frequently if necessary, 
a tablet composed of Calomel, Digitalis, and Squills, 
eacli one grain, and Muriate of Pilocarpine, one- 
twentieth of a grain, followed in the morning by a 
full dose of Yillacabras water. 

"Finally, when exercise cannot be taken and an 
abundant supply of fresh air is wanting, oxygen in- 
halations will prove of service. 

" Every case must be treated on its merits. In 
one a restricted diet and mild stimulation of the renal 
and intestinal functions is sufficient, and the patient 
may be allowed to be about and even exercise in the 
open air, the skin being protected from sudden changes 
by being incased in wool or flannel. More pronounced 
cases of eliminative insufficiency must be kept abso- 
lutely quiet in bed, upon an exclusive milk diet, with 
the stimulation of all the eliminative organs. 

"The hygienic and medicinal treatment is only of 
secondary importance to the milk diet, which is the 
foundation of the preventive treatment of puerperal 
eclampsia. When, in spite of an exclusive milk diet 
and the vigorous stimulation of the five excretory out- 
lets, the symptoms and signs of the pre-eclamptic 
condition continue or at any time become urgent, 
the indication is to induce artificially abortion or pre- 
mature labor. 

" Curative treatment also has three indications : to 
control the convulsions ; eliminate the poison or poisons 
which we presume cause the convulsions ; empty the 



ALBUMINURIA OR ECLAMPSIA OF PREGNANCY. I 1 9 

uterus under deep anaesthesia, by some method that 
is rapid and that will cause as little injury to the 
patient as possible. 

"The four medicinal means most certain and safe 
as anti-eclamptics are Chloroform, Morphine (hypoder- 
maticallv), Veratrum viride, and Chloral hydrate, the 
latter alone or combined with Sodium bromide. His 
preference is for Chloroform, Veratrum viride, and 
Chloral, in the order named. Morphine he has aban- 
doned almost entirely, as he believes it prolongs the 
post-eclamptic stupor and increases the tendency to 
death during coma by interfering with the eliminative 
processes. 

" Second only to Chloroform in value is Veratrum 
viride. Provided the pulse be strong as well as rapid, 
it is the most certain means for temporarily and even 
permanently controlling the convulsions. When the 
pulse is weak he relies upon Morphine hypodermatic- 
ally, Chloroform by inhalation, and Chloral by rectum, 
with stimulation if necessary. 

" (1) Veratrum viride reduces the pulse rate, and 
convulsions are practically unknown with a pulse rate 
of 60 or under; (2) it reduces the temperature; (3) 
it relaxes and renders more yielding the rigidity of the 
cervical rings ; (4) it causes prompt diaphoresis and 
(5) diuresis, so that it aids not only in the fulfilment 
of our first indication, the control of the convulsions, 
but in the second, the elimination of an unknown poison 
as well. Norwood's tincture should always be used ; 



I 20 ALBUMINURIA OR ECLAMPSIA OF PREGNANCY. 

five drops hypoderniaticalry, or 10 to 30 drops by 
mouth, as the pulse, etc., indicates. 

" He secures catharsis as early aud as promptly as 
possible by the administration of Croton oil, compound 
Jalap powder, or Calomel, followed by salines aud 
high euemata of Magnesium sulphate. In the 
coma or post-eclamptic stupor of the condition, he 
relies upon the repeated administration of concen- 
trated solutions of Magnesium sulphate or Villacabras 
water, by means of a long rectal tube high up in the 
descending colon. The hypodermatic administration 
of Magnesium sulphate is too slow and uncertain. 
Diuresis is obtained by dry or wet cups over the 
kidneys, followed by hot fomentations. Glonoin, as 
a diuretic and anti-eclamptic, cannot be overestimated. 
Diaphoresis is encouraged by means of the hot-air 
bath or the hot pack. Pilocarpine, as a diaphoretic, 
in the presence oi an eclamptic attack, is utterly re- 
jected, because of the danger of oedema of the lungs 
and glottis which it may produce. The drawing off 
of large quantities of toxic liquids in the form of 
blood or serum, by means of venesection, catharsis, 
diaphoresis, diuresis, followed by the replacement of 
the same, by intravenous, stomachic, rectal or hypo- 
dermatic means, causing a washing or disintoxication 
of the blood and tissues as it were, has thus far 
proved of doubtful value. In instances of collapse, 
however, with the small compressible pulse, the intro- 
duction into the blood of a normal saline solution is 
of the same value here as in collapse under other 



ALBUMINURIA OR ECLAMPSIA OF PREGNANCY. I 2 I 

circumstances. As a general stimulant, to assist in 
the elimination from the lungs and to prolong life in 
the post-eclamptie stupor or coma, he has found the 
free administration of Oxygen of the greatest value. 
Further, Alcohol will often be needed as a stimulant 
during and after an eclamptic attack, and Strychnine 
in the post-partuni state and in the face of threatened 
collapse — although for physiological reasons it would 
seem to be contra-indicated." 



CHAPTER XVI. 
Renal Tuberculosis, 

Etiology. — When it is primary, the lesion may in- 
volve in its early stage one kidney only. When secondary 
to a tubercular condition of the lungs, intestines, lym- 
phatic glands, bladder, prostate, seminal vesicles, testes, 
labia, fallopian tubes, ovaries, or developing in the 
course of a general tuberculosis, it is usually bi- 
lateral. There are three forms of renal, tuberculosis: 
the descending form, where the disease commences in 
the kidney and is usually uni-lateral ; the ascending 
form, in which some of the sub-renal tissues are first 
involved; this is usually bi-lateral; and a third form, 
in which the whole genito -urinary tract is simultaneously 
involved. 

The one direct cause of renal tuberculosis is the 
presence in the tissues of the tubercular bacilli and 
their ptomaines. The predisposing cause is some in- 
herited or acquired weakness of the kidney. As a 
primary affection it is of much interest, but when 
appearing in the course of a general systematic tuber- 
cular invasion, it is not characteristic or of great 
importance. It is a disease essentially of early middle 
adult life, yet it has developed as early as the third 
month, and as late as the 72nd year. It appears 
nearly twice as frequently in the male as in the 
female, and it develops in about 4 per cent, of all cases 



RENAL TUBERCULOSIS. I 23 

of general or local tuberculosis. When primary it 
is thought by some to be caused by direct in- 
fection during the act of copulation, especially when 
the disease has extended through the geni to -urinary 
tract, though its cause is probably haematogenous. 

Pathological Anatomy. — When the lesion is a 
part of a general miliary tuberculosis, the kidney tissue 
and the surface of the organ are studded with miliary 
tubercules. The structure surrounding the tubules 
undergoes no material change. Both kidneys are usu- 
ally affected. 

The kidney may be the seat of a primary tuber- 
cular infection, or the organ may have become infected 
by the extensiou of a pre-existing tubercular lesion 
in some neighboring urinary organ. In each instance 
the pathological condition is the same. 

As a rule, but one kidney is affected, and the left 
more frequently than the right. 

The inflammation generally begins in the mucous 
membrane of the pelvis, and gradually extending into 
the pyramids and then the cortex, finally involves a 
greater part or the whole of the kidney. 

The formation of tubercle tissue begins in the 
stroma. The epithelium of the neighboring tubules 
proliferate and subsequently become necrotic. The 
affected areas undergo cheesy degeneration with the 
formation of cavities, varying in size and number, 
according to the extent of the lesion and contain a 
cheesy mass, in the substance of which may be found 
the tubercle bacillus. 



124 RENAL TUBERCULOSIS. 

The portions of the kidney not affected by the 
tubercular inflammation are very apt to undergo an 
interstitial inflammation of the chronic type. 

Sometimes the disease is self-limited, and the areas 
of cheesy degeneration are seen to have been in- 
filtrated with the salts of lime. 

Clinical History. — In primary tuberculosis of the 
kidney there is usually a certain amount of involve- 
ment of the general genito-urinary organs before its 
discovery. At first, when the parenchyma only is in- 
volved, there are no symptoms; pain, etc., develop- 
ing simultaneously with the involvement of the mucous 
membrane, or when a tubercular abscess opens into the 
pelvis of the kidney. Sometimes at the first examina- 
tions the diseased kidney can be distinguished as a 
tumor on the affected side. There is soreness referred 
to the lumbar region, with an occasional lancinating or 
burning pain extending down the groin into the testes 
or labia, which increases during micturition ; it may 
be increased by motion, and some, to lessen the pain, 
fix the parts and keep them quiet by acquiring an 
apparent lateral curvature of the spine. As the pelvis 
of the kidney and the uretral opening at the bladder 
becomes involved, micturition becomes more frequent 
and distressing. The urine at first may be increased in 
quantity, but in other respects appears apparently normal; 
when the bladder becomes to some degree involved, 
or a pyonephrosis develops, it may become alkaline, and 
contain tubercle bacilli, small cheesy masses, pus, albumen, 
and occasionally a little blood. Hematuria, however, is 



RENAL TUBERCULOSIS. I 25 

not a constant symptom, as it is in cancer of the 
kidney, though Pousson, Jour, de Med. de Bordeaux, 
1895, reports a case of primary renal tuberculosis in 
which there was profuse and long continued hemorr- 
hage without other change in the character of the 
urine. The hematuria is not influenced by exercise. 
If the tubercles at any point in the kidney rupture 
and discharge their bacilli, their presence in the urine 
with pus, blood corpuscles, fibrinous shreds, etc., will 
establish the diagnosis. Renal casts are sometimes 
present, but they are unimportant. If the disease is 
confined to one kidney, the plugging of its ureter by 
a cheesy mass may at times cause the urine voided to 
appear clear and natural. In all obscure urinary dis- 
eases, especially when primary tuberculosis of the 
kidney is suspected, a cystoscopic examination of the 
bladder should be made and the ureters catheterized. 
The diagnostic indications by the cystocope are as 
follows : the bladder walls surrounding the uretral 
openings appear congested, and may have the appear- 
ance of foot-prints in snow. If the urine flowing from 
the uretral catheter contains tubercular bacilli, and 
the urine and ureter of the opposite side are normal, 
local tuberculosis may be positively diagnosticated. 

Frequent micturition in childhood, with mucus in 
the urine, is frequently the forerunner of renal 
tuberculosis, and when accompanied by painful mic- 
turition, has been mistaken for stone in the bladder. 

\Vhen the symptoms simulate stone in the bladder, 
the rise of temperature, which occurs in tuberculosis, 
will differentiate the two conditions. 



126 RENAL TUBERCULOSIS. 

Frequent micturition, accompanied with urinary in- 
continence, without apparent cause, should always ex- 
cite apprehension of a tubercular involvement of the 
kidney, especially if there is tubercular family history. 

As the disease progresses, emaciation, hectic fever, 
loss of strength and general systemic involvement, 
with diarrhoea and vomiting, appear. 

The disease is usually fatal, although in some cases 
life may be prolonged for years : a few have apparently 
recovered. 

In secondary tubercular involvement of the kidney 
the symptoms are unimportant, though pain and sore- 
ness, referred to the lumbar region, with albu- 
minous urine, would make us especially careful in 
regard to the prognosis. If tubercular bacilli are 
found in the urine, the case must be considered hope- 
less. 

Treatment. — Arsenicum iodatum, Calcarea iodata, 
Kali iodatum, Hekla lava, Chininum arsenate, Chininum 
sulphate, Calcarea hypophosphorica, Calcarea carbonica, 
and Kreosotum must be prescribed as indicated by their 
general symptomatology ; see indications in Chapter 
XL.; and Bacillinum, 30 or 200, a dose once a week, 
as advised for tubercular conditions in other parts 
of the body, should be tried. 

Change of air and surroundings, with general hy- 
giene or a sea-voyage, will be beneficial when the 
urinary symptoms will allow. 

In the early stage of primary renal tubercu- 
losis, much may be expected from a change of 



RENAL TUBERCULOSIS. I 2 7 

climate. A dry, equable climate should be selected. 
High altitudes with too cold an atmosphere are rarely 
beneficial; cold is particularly unsuited to these patients, 
since chilling of the surface greatly increases the 
kidney lesion : hot, dry climates have the dis- 
advantage of causing concentrated urine, which dis- 
tinctly increases the bladder irritability. A nephrotomy 
with proper drainage of the tubercular pus cavity is 
sometimes beneficial, and removal of the diseased kid- 
ney may be indicated when a cystoscopic examination 
of the bladder and catheterization of the ureters demon- 
strate the healthy condition of the other kidney. The 
immediate results of this operation are often brilliant, 
both as to relief of the suffering and mortality ; in some 
cases a cure may be hoped for, but usually the 
diagnosis cannot be made sufficiently early for the 
operation to be of any permanent benefit. 

The frequent and painful micturition in some of 
the more chronic cases may require for its relief a 
cystotomy for drainage. 



CHAPTER XVII. 
Renal Syphilis. 

Acute Syphilitic Nephritis. 

Etiology. — It frequently develops early in the 
secondary stage of syphilis, i. e., eight to twelve weeks 
after the original chancre. Albuminuria occurs in 
about four per cent, of all syphilitics. 

Pathological Anatomy. — The uriniferous tubules 
are congested and the gross appearance of the kidney 
is very similar to that of the exudative nephritis occur- 
ring after scarlet fever. 

Clinical History. — Micturition becomes frequent, 
the urine is reduced in quantity and contains albu- 
men, blood, ejrithelial, hyaline and granular casts; 
oedema may be general or amount only to a slight 
puffiness under the eyes ; headache and slight digestive 
disturbances are common. 

Prognosis. — Resolution is rapid. 

Treatment. — Mercurius corrosivus generally covers 
the totality of the symptoms ; the general care is 
that advised for acute parenchymatous nephritis. 

Chronic Syphilitic Nephritis. 

Etiology. — In the later stages of syphilis interstitial 
hyperplasia, gummata and amyloid degeneration often 
develop without special symptoms except the presence 
of albumen and casts in the urine. 



RENAL SYPHILIS. I 29 

Pathological Anatomy. — The kidney may show 
amyloid degeneration, interstitial inflammation, or de- 
veloping gummata ; the three conditions are frequently 
associated, the amyloid condition predominating. 

Clinical History. — The symptoms vary little, if 
any, from those of chronic nephritis. As the disease 
advances and the gummatous growths break down, 
the urine becomes turbid, of a dirty brown color, 
contains albumen, a large quantity of detritus, with 
blood and epithelial cylinders. 

Treatment. — Good results will follow anti- syphilitic 
treatment, a milk or mixed diet, with good hours and 
hygiene. 



CHAPTER XVIII. 
Renal Tumors. 

Kidney enlargements may be congenital or acquired. 
The congenital comprising simple and dermoid cysts, 
hydronephrotic conditions, cavernous tumors, which 
give no recognized symptoms and are little under- 
stood, and sarcomatous growths. 

The acquired are naturally divided into the extra- 
renal, pelvic, capsular, and glandular varieties. Extra- 
renal tumors include perinephritis, extrarenal cysts, 
which are sometimes only discovered at the autopsy 
having given no clinical evidence of their presence. 
Myxolipomatous tumors sometimes develop in the 
perirenal tissue, and attain considerable size. In ma- 
lignant renal growths it is sometimes impossible to 
differentiate the intra- from those of extrarenal origin. 

The pelvic variety includes hydro- and pyonephro- 
sis, tubercular pyelitis, sarcoma and carcinoma. Villous 
tumors are rare, but when present they may develop 
to an enormous size. The glandular and capsular 
varieties include simple, hydatid and dermoid cysts, 
tubercular growths, and syphilitic gummata, which may 
be recognized by the specific history, and the relief 
produced by anti-syphilitic treatment. Lymphacle- 
nomatous growths are uncommon ; they sometimes 
accompany Hodgkins' disease. Endotheliomata are 
also rare ; the history of two cases, and their patho- 



RENAL TUMORS. I 3 I 

Logical specimens, were presented to the N. Y. 
Pathological Society, April 8th, 1896, by Dr. G. A. 
Tuttle. In one case there was pain, dragging in 
character, in the right- groin, extending into the 
testicle ; urination was scanty, with frequent night 
sweats. The tumor was the size of a cocoanut, occu- 
pied the right renal region, and was successfully re- 
moved. A number of small innocent growths some- 
times develop, but as they present no clinical symptoms, 
they cannot be distinguished during life. 

The symptoms of renal growths are not definite or 
constant — in fact, these are considered the most dif- 
ficult of all abdominal tumors to differentiate. Renal 
tumors develop more frequently in childhood and after 
the fortieth year. 

Malignant groivtlis of the kidney. 

They may be either carcinomatous or sarcomatous. 
In many respects they present similar symptoms, and 
may, therefore, be described together and their special 
points of difference noted. 

Etiology. — No known, real or undoubted cause 
exists. The sarcoma is especially a disease of child- 
hood, and usually develops before the eighth year. 
From this period until late in adult life malignant 
disease of the kidneys is rare, but when it does occur, 
it is generally cancerous, and of the medullary variety. 

In nearly all there is a history of a fall, blow or 
strain, generally referred to the renal region. 

Pathological Anatomy. — The following benign 



I 3 2 RENAL TUMORS. 

growths are occasionally found in the kidney : Lipoma, 
Fibroma, Myoma, Angioma, Papilloma. 

They are, as a ride, small, and give no clinical 
evidence of their presence. They are seen at autopsies, 
when no lesion of the kidneys has been suspected. 

Adenoma. — These tumors may be villous or alveolar 
in type. They vary in size, some being as small as 
a pea, and others of large size. Delafield and Prudden 
describe a papillary adenoma, which involves the whole 
of the organ, and is malignant. 

Carcinoma. — This form of tumor is rare. It was 
once considered the most common form of malignant 
tumors of the kidney, but it is now generally 
admitted that many of the tumors which had been 
described as carcinomata were, in reality, sarcomata. 
It is often difficult to differentiate the two. When 
true carcinomata are found in the kidney they are 
generally metastatic. 

McNeeney, in the British Medical Journal, Feb- 
ruary 8, 1896, describes two renal tumors, whose 
structure bears a semblance to suprarenal tissue. He 
is disposed to class them with the carcinomata. 

Sarcoma. — Malignant growths of this class are by 
far the most common found, originating in the renal 
tissue. They may be of the round or spindle cell 
variety. There are also several mixed types described 
— i. e., liposarcoma, myosarcoma, myxosarcoma ; the 
last named are apt to originate in the pelvis of the 
kidney. 

They may begin their growth outside the kidney, 



RENAL TUMORS. I 33 

involving the organ by their peripheral growth, or 
their origin may be in the renal structure or in the 
pelvis. 

Sarcomata are prone to grow to large size. They 
are soft and often break down, giving rise to hemor- 
rhage of greater or less severity within their sub- 
stance. Pressure of the tumor on the ureter may 
produce hydronephrosis. Thrombosis of the inferior 
vena cava may occur from the same cause. 

They occur in the right kidney about as often as 
in the left, but rarely in both at the same time. They 
sometimes grow to an enormous size. Jacobi reported 
one weighing 36 pounds. 

Clinical History. — From three-tenths to one 
per cent, of all malignant growths occurring in 
the human body originate in the kidney. When the 
disease is primary one kidney only is usually involved, 
while in the secondary form both are equally diseased. 
The growth may extend upwards, involving the spleen 
and lungs or liver and lungs, interfering with respiration, 
or downward into the illiac region of the side diseased 
and forward into the epigastric region. The size of 
the tumor can be approximately denned and distingu- 
ished by placing the fingers of one hand along the 
lower ribs behind and external to the larger muscles 
of the back, and the fingers of the other hand below 
the ribs in front, then on deep expiration, especially 
in a thin subject, the change in size of the kidney 
can be easily ascertained. It is usually immovably 
attached to the neighboring parts and on percussion 



134 RENAL TUMORS. 

there may be tympanitic resonance in front when it is 
covered by the colon. 

Pain in the diseased kidney is quite a constant 
symptom, though frequently absent in sarcoma ; it is 
usually spoken of as a continuous dull soreness, not 
especially affected by motion or position and does not 
shoot into the neighboring parts, down the groin, into 
the testicles or labia. The tumor is usually some- 
what sore to touch. 

The urine may at all times be normal, especially 
if the disease has developed external to the kidney, 
but as the parenchyma of the kidney becomes involved 
there will be blood in the urine, which may be slight 
and transitory or continuous and profuse, producing 
marked anaemia, etc., and gives the urine the color of 
porter, and frequently it contains small clots of blood. 
The hemorrhage is not affected by motion, position, or 
time of day, as occurs in the hsematuria from calculi in the 
pelvis of the kidney. About one half of all cases of 
malignant disease of the kidney have a history of frequent 
or constant hematuria. The genital organs are rarely 
involved, while other organs rarely escape secondary 
involvement. As the disease advances the cancerous 
cachexia, emaciation, constipation or alternate constipa- 
tion and diarrhoea, loss of appetite, etc., become more 
marked, and death finally ensues. 

Death has been known to occur as early as the 
ninth week, while some have existed for a period of 
three to fifteen years, and others, after operation, 
have apparently recovered, to die ultimately. When 



RENAL TUMORS. I 35 

the renal tumor is a carcinoma they survive from 
three to fifteen years ; sarcomatous patients may live 
two or three years, and those with epithelioma 
between two and fifteen years. 

Treatment. — Arsenicum album is frequently indi- 
cated and gives more relief than any known remedy. 
The hematuria may require Ferrum, Millefolium, 
Hamamelis Virginica, Secale, Ipecacuanha or Erigeron. 
The general building up of the system with nutritious 
and easily digested food must receive attention. If 
the cancerous condition is recognized early, when the 
disease is uni-lateral, the diseased kidney must be 
at once removed. The percentage of deaths from this 
operation is large, but many cases have apparently 
found relief and cure in a nephrectomy. 



CHAPTER XIX. 
Hydronephrosis. 

Hydronephrosis is an over-distension of the pelvis 
of the kidney with liquid, usually urine. 

Etiology. — It may be congenital or acquired, 
permanent or temporary. The causes are numerous 
and are sometimes un discoverable ; the most frequent 
is obstruction to the natural exit of the urine. 
When this obstruction is above the bladder it produces 
hydronephrosis of one side only ; when below, it will 
affect the pelves of both kidneys. Occlusion or 
absence of one or both ureters is the usual congenital 
cause. A calculus, blood clot, a mass of pus or any 
other foreign matter obstructing the ureter may per- 
manently or temporarily close the ureter ; sometimes a 
calculus acts as a ball valve. Tumors or growths of 
various kinds, either within, upon, or external to the 
ureter, will, by their impingement upon the calibre of 
the canal, cause this condition. It is also caused by 
retroflexion of the uterus, cicatricial tissue produced 
either from local inflammations, the result of surgical 
operations or injuries caused by the passage of calculi 
through the ureter, from twists and loops in the 
ureter, or from a movable or floating kidney. The 
abnormal origin of the ureter in the pelvis of the 
kidney, or when inserted into the bladder obliquely, 
may produce a valve-like opening, which, under certain 



HYDRONEPHROSIS. I 3 7 

conditions, would cause obstruction to the natural flow 
or exit of the urinary secretion, and produce hydrone- 
phrosis. The causes of double hydronephrosis are: 
polyuria, obstructions in the bladder, as large stones, 
tumors within, upon and external to the bladder, 
enlarged prostate, stricture of the urethra, and can- 
cerous or other growths at any point on or adjacent 
to the genito-urinary tract. 

Pathological Anatomy. — The ureters are dilated 
and their walls hypertrophied. They are sometimes 
sacculated and as large as small intestines. 

The pelvis of the kidney on the affected side is 
dilated, sometimes emormously so, forming a large 
cystic tumor. The calices are each dilated, forming 
cysts. 

The kidney tissue immediately surrounding the di- 
lated portions is flattened. The rest of the kidney 
may undergo interstitial inflammation and pyelo-nephritis 
may be the result. 

The dilated portions contain urine or, if suppura- 
tion has taken place, the urine may be mixed with 
pus. 

Clinical History. — If congenital and bi-lateral it 
is rapidly fatal. The acquired form occurs more fre- 
quently in the male than the female. The subjective 
symptoms in many cases are wanting or are very 
obscure, and many patients live with this condition 
for twenty or thirty years without special inconveni- 
ence. Occasionally a hydronephrotic sac empties 
itself and spontaneous recovery occurs ; but usually 



130 HYDRONEPHROSIS. 

it slowly increases in size. A large hydronephrotic 
tumor is uncommon. There is some uneasiness and 
fullness referred to the affected loin and lumbar region, 
which may appear somewhat fuller and more distended 
than the opposite side. When large, the tumor may 
press on the lower part of the alimentary canal, caus- 
ing constipation, or by its pressure upward upon the 
diaphragm and thoracic viscera, produce dyspnoea. It 
rarely causes death unless complicated by or associated 
with some other disease. When the abdominal walls are 
thin, the sac may be made out as an elongated, some- 
what kidney-shaped, tumor. Usually it is not tender to 
the touch or to manipulation, but gives fluctuation on 
palpation and flatness on percussion unless it is covered 
by the colon or a coil of the small intestines, which 
may occur if the disease has developed in a kidney 
previously movable or floating. 

Diagnosis. — Obstruction to the urinary duct has, in 
new-born infants, caused hydronephrosis and death. 
It is not necessary to have a complete obstruction to 
cause hydronephrosis. If the swelling in the loin 
and lumbar region disappears at times, followed by 
an unusual flow of urine, the diagnosis may be con- 
sidered established ; sometimes when the sac is very 
large a positive diagnosis is very difficult, as it might 
be mistaken for an ovarian tumor. (But ovarian 
growths increase in size from below upwards, while 
the sac produced by hydronephrosis increases from above 
downwards.) In hydatids of the liver or kidney 
aspiration and examination of the fluid will clear the 



HYDRONEPHROSIS. 1 39 

diagnosis. The hydatid cyst contains the characteristic 
hooklets ; the ovarian, the Graafian cells ; and the cyst 
in the hydronephrosis contains urea, cholesterin crystals 
and urine. In cancerous growths the cachexia, loss of 
strength, emaciation and fever will materially assist in 
the diagnosis. 

Treatment. — This varies greatly according to the 
size of the cyst and the concomitant symptoms. 
When there is no discomfort, the expectant plan of 
treatment, followed by gentle massage, has, in some 
cases, caused the sac to empty itself. If, however, 
the distress becomes persistent, or the tumor presses 
upon the neighboring organs, aspiration may become 
necessary. Sometimes successive aspirations results 
in a cure. On the right side the aspirating needle 
should be introduced midway between the last rib 
and illiac crest, and on the left, at the anterior ex- 
tremity of the eleventh intercostal space. The ut- 
most asceptic precautions must be observed in the 
operation, as infection has been known to transform 
the hydronephrosis into a pyonephrosis ; therefore 
when frequent aspiration is indicated, it would be 
preferable to incise and properly drain the cyst. 

When the hydronephrosis is the result of obstruc- 
tion by a calculus, an operation through the lumbar 
region, for its removal, will be required ; this in 
many cases has resulted in a urinary fistula, and, 
therefore, many prefer to make a nephrectomy. 



CHAPTER XX. 
Pyonephrosis. 

Pyonephrosis is a collection of pus, distending the 
pelvis of the kidney. 

Etiology. — The causes are similar to those ot 
hydronephrosis. In the course of a pyelitis, if the 
ureter becomes obstructed, pyonephrosis develops. 
A calculus, which at first irritates the pelvis of the 
kidney, may cause inflammation, and the. discharge of 
pus finally obstructs the ureter, with consequent re- 
tention of pus and urine. Tuberculosis of the kidney 
and its pelvis is another cause, the discharged cheesy 
mass obstructing the ureter. Injuries of various kinds, 
and especially the pressure exerted during gestation, 
or from the uterus being pressed against the ureter 
or the pelvis of the kidney, may cause inflammation, 
formation of pus and obstruction. A hydronephrosis 
may be transformed into a pyonephrosis from care- 
less aspiration for diagnosis or treatment, from rupture 
of an abscess in the kidney structure into an oc- 
cluded pelvis, or the obstruction of the ureter by 
cheesy masses or blood clots. There are cases which 
are undoubtedly due to invasion of the ureter and 
pelvis of the kidney by an ascending gonorrhea, causing 
obstruction of the ureter and pyonephrosis. 

Pathological Anatomy. — The mucous membrane of 
the pelvis is thickened. It is covered with fibrin 



PYONEPHROSIS. 141 

and pus, and there is a necrosis of the superficial 
layers of epithelium. 

If the condition has existed for a considerable 
length of time, it is apt to result in a suppurative 
nephritis, or a chronic interstitial nephritis. 

Clinical History. — If pus is occasionally found 
in the urine, accompanied by a decrease in the 
fullness of the affected side, the diagnosis will be 
easy. The general objective symptoms are similar to 
those of hydronephrosis, but as the disease progresses, 
symptoms of sepsis appear. As this condition de- 
velops, the renal region becomes sore and sensitive 
to touch. The abscess may open into the peritoneum 
and cause shock and death. It may open into the 
surrounding organs. The duration of this disease is 
from three months to three years. 

Treatment. — Attention must be given to the general 
building up of the system. In many cases drainage of 
the bladder has given great and permanent relief, but a 
nephrotomy or nephrectomy is only indicated when 
the disease is uni-lateral. If possible, the uretral ob- 
struction must be removed. If it is of recent occur- 
ence, massage, with ingestion of large quantities of 
fluid, has in some cases been successful. If there is 
evidence of partial or complete obstruction to one 
ureter, and constitutional symptoms of pus absorption 
appear, surgical relief must at once be given as re- 
quired by the individual case — i. e., aspiration, neph- 
rotomy, or nephrectomy. 



CHAPTER XXI. 
Pyelitis. 

Pyelitis is an inflammation of the pelvis and the 
calices of the kidney. The proximal end of the 
ureter is usually involved. 

Etiology. — One or both pelves may be diseased, 
affecting one side when the cause is not lower down 
than the ureter or is local in character. When both 
are affected, it may be the result of constitutional 
disorders, diseases of the bladder or prostate, stricture 
of the urethra, etc. 

It may be primary or secondary, acute or chronic. 

Acute primary pyelitis occurs during the course 
of the infectious diseases, i. e n typhus, typhoid, pyaemia, 
influenza, cholera, diphtheria, scurvy, scarlet fever, 
measles, etc. It may be caused by the chemical 
action of certain drugs, as Cantharides, Turpentine, 
Copaiva, Sandal wood, and some of the diuretics; by 
mechanical pressure as in hydronephrosis, or from in- 
fection by bacteria from the colon, or the result of 
exposure to damp and cold. 

Chronic primary pyelitis is divided into the trau- 
matic, calculous and tubercular. 

Traumatic is of mechanical origin, occurring with 
or without uretral obstruction. 

Tubercular pyelitis is dependent upon tubercular 
growths in the pelvis of the kidney. 



PYELITIS. 143 

Calculous pyelitis is produced by the presence of 
a calculus in the pelvis of the kidney. If it can be 
dissolved or dislodged, the case can be cured, other- 
wise the symptoms of pyelitis will gradually become 
more distressing. 

Acute secondary pyelitis is usually due to an ascend- 
ing gonorrhea, or a simple cystitis. 

Chronic secondary pyelitis is frequent. It may be 
caused by obstruction of the urinary flow by stric- 
tures of the urethra, an enlarged prostate, a chronic 
cystitis, pressure of tumors on, or a retained stone 
in the ureter, to irritating crystals in the urine from 
lithsemic or gouty conditions, or chronic catarrhal 
conditions resulting from altered metabolism, especi- 
ally seen occurring in paraplegia and other forms of 
spinal disease. 

Pathological Anatomy. 

Acute primary pyelitis. — In the milder cases there 
may be a congestion of the mucous membrane of the 
pelves and calices, and a simple swelling of the sur- 
face epithelium. In the more severe cases the 
mucous membrane is coated with an exudate of fibrin 
and pus. The bacteria of suppuration may be present, 
and the suppurative inflammation may invade the 
kidney tissue, giving rise to a suppurative nephritis. 

Chronic primary pyelitis. 

The mucous membrane of the pelves and calices is 
thickened, the epithelium is swollen and necrotic. 
The inner surface of the pelvis is covered with pus, 
fibrin, and the dead epithelium. 



1 44 PYELITIS. 

Acute secondary pyelitis. 

The inflammation may be directly continuous with 
that of the lower urinary passages, or the ureter may 
be intact. 

The mucous membrane may be simply congested, 
with a swelling of the epithelium, or there may be 
an exudation of serum, fibrin and pus, with swelling 
and death of the epithelium. 

Chronic secondary pyelitis. 

There is a thickening of the mucous membrane of 
pelves and calices. The epithelium is swollen and 
granular. There is a growth of granulation tissue 
beneath the epithelium. 

When there are tubercular growths in the pelvis, 
there is in addition a more or less diffuse exudative 
inflammation. The exudate contains tubercle bacilli. 

Clinical History. — In general there is pain referred 
to the lumbar region of one or both sides, with tenderness 
and soreness on deep pressure. The pain follows the 
course of the ureters, shoots into the perineum and 
thigh, and is accompanied by frequent and painful mic- 
turition. The urine usually contains pus, and may be acid 
or alkaline in reaction ; tailed epithelium may be found, 
but their absence does not contra-indicate pyelitis. The 
general symptoms are such that the pyelitis is frequently 
overlooked in making a diagnosis. It is always im- 
portant to differentiate between primary and secondary 
pyelitis. 

Acute primary pyelitis. 

It may be so slight as to escape notice, or, if diagnos- 



PYELITIS. 145 

Ideated, is of slight importance compared with the 
exciting cause. There may be chill, fever, intense 
pain in the region of the kidney, with scanty, puru- 
lent and albuminous urine, the condition being accom- 
panied by involvement of the kidney tissue — (a true 
pyelonephrosis). This is a very severe form of the 
disease and is usually bi-lateral. Surgical treatment 
is of no avail. The remedies most frequently required 
and which are sometimes brilliantly successful are 
Aconite, Veratrum viride, Belladonna, Hepar sulphuris, 
Hekla lava, Sodium sulpho-carbolate, etc. 

Chronic primary pyelitis develops slowly and in- 
sidiously, though it sometimes is the immediate result 
of a blow or fall upon the lumbar region. There is 
aching and uneasiness in the renal region, which at 
first may be transitory and accompanied by some 
tenderness and soreness on deep pressure. 

The urine is acid in reaction with a specific gravity 
of about 1030, contains blood, pus-corpuscles, mucus, 
tailed epithelium, etc. As the disease advances the 
pus increases in quantity. The pus does not collect 
in masses, it is not ropy, but remains separated, 
giving a turbid appearance to the urine, and on 
standing settles to the bottom of the vessel. As the 
disease progresses the epithelial cells gradually dis- 
appear from the urine. The reaction of the urine is 
usually acid, differing from the alkaline urine of 
cystitis. 

When the pelvis of the kidney is sacculated, the 
urine may become ammoniacal and very offensive, 



1 46 PYELITIS. 

being fouled easily from the adjacent colon or 
by sepsis of the bladder, occasioned by surgical un- 
cleanliness and the pus which, up to this time, has 
been mixed with the urine, rapidly separates from the 
acid urine, and becomes thick, solid, and stringy. 

The microscope may reveal crystals of ammoniaco- 
magnesian phosphates, irregular and worm-eaten from 
contact with the acid urine. The most characteristic 
symptom of this disease, however, is an acid urine 
containing a variable quantity of pus, with a painful, 
tender and swollen kidney, which possibly gives evi- 
dence of fluctuation. Sometimes the breath and per- 
spiration will exhale the peculiar odor of ammonia. 
In these cases beware of urethral instrumentation. 
The amount of albumen varies according to the quan- 
tity of pus and blood present in the urine. In pyelitis, 
when the ureter is free throughout its whole extent, 
pus will be constantly found in the urine, but if it be- 
comes obstructed a tumor may be developed between 
the crest of the ilium and the last rib, giving a slight 
prominence to the affected side. When the obstruc- 
tion is removed this tumor will disappear and large 
quantities of pus will be discharged with the urine. 

In chronic pyelitis there will be fever, emaciation 
and weakness, often chill, fever and sweat (hectic), 
occurring at regular intervals, generally in the evening. 
This is especially true in conditions of pyonephrosis 
from occlusion of the ureter. When the pelvis of 
only one kidney is affected the kidney structure some- 
times becomes absorbed from pressure or disease and 



PYELITIS. 147 

results in the formation of an encysted collection of 
pus. 

Traumatic pyelitis varies with the severity of the 
traumatism. If the injury has been slight it may be 
followed by a little hematuria and few or no symp- 
toms, or again, pus may appear in the mine together 
with all the symptoms of pyelitis. The majority soon 
recover, others become chronic and removal of the 
diseased organ may be required. 

Calculous pyelitis is caused by the presence in 
the pelvis of the kidney of one or more calculi. 
Women seem more prone to this disease then men. 
It may be present with pyuria for years with- 
out producing symptoms or change in the size of 
the kidney. Pain in the kidney region is usually 
present ; it may be intermittent, moderate or ex- 
cruciating. There are at times sharp twinging pains 
occasioned by the stone partly engaging itself in the 
opening of the ureter; or symptoms may be absent until 
long after pus has been found in the urine. As the 
case progresses the kidney increases somewhat in size, 
due to the swollen condition of the kidney and pelvis, 
or to retained fluid. Hematuria may accompany the 
pyuria. If an acute pyelitis is in any way added to the 
chronic condition it is usually severe. 

Tubercular pyelitis is in fact a true pyonephrosis, 
or soon becomes one. It may remain sub-acute in 
character, causing little pain or fever ; the urine is 
acid in reaction, laden with pus, albuminous, of low 



148 PYELITIS. 

specific gravity, and tubercle bacilli appear in the 
urine. 

Secondary pyelitis is undoubtedly the most frequent 
form of pyelitis and the least frequently recognized. 
It is due to an ascending inflammation along the 
ureter to the pelvis of the kidney from some 
disease or to obstruction in the bladder, prostate or 
urethra. 

Acute secondary pyelitis is fortunately rare. It usu- 
ally terminates fatally. It is caused by injudicious 
instrumentation of the genito-urinary tract in those 
suffering from prostatic disease or tubercular cystitis, 
especially in those past the 50th year in whom the 
lithaemic condition is well marked or by the sudden 
removal of the urinary pressure of a hydronephrosis. 

A tubercular bladder is very intolerant of instru- 
mentation, even in the early stage of the disease: 
the male bladder is less tolerant than the female. 
Washing of the bladder in this class of cases has 
caused acute ascending pyelitis, which announces itself 
sometimes within two hours after the instrumentation 
by a rise in temperature, etc. Therefore instrumental 
examination of an inflamed bladder with a nodular or 
tubercular prostate, must never be attempted without 
proper care and deliberation. 

In lithsemia, the mucous membrane of the pelvis of 
the kidney and ureter is constantly eroded and irri- 
tated by the excess of urates which passes over it, 
and consequently they are not in a condition to stand 
sudden shock or inflammatory invasions. Instrimienta- 



PYELITIS. 1 49 

tion, unless care fully made, with the most strict asepsis, 
may quickly light up a severe and fatal pyelitis. In 
the aged, urinary obstruction from an enlarged prostate 
causes first a dilated and sacculated bladder, and 
finally a hydronephrosis; slow continued pressure is 
made on the secreting tissues of the kidney, and 
the urine simply strains through. Digestive dis- 
turbances and weakness usually accompany the con- 
dition. In this class of cases, the sudden removal 
of the urine may result in acute congestion of the 
pelvis of the kidney and death in from five to ten 
days from acute pyelitis. 

When acute secondary pyelitis is the result of an 
ascending gonorrhoea, the pyelitis is usually sub-acute 
in character and rarely fatal: in the tubercular vari- 
ety it is usually uni-lateral. 

Acute secondary pyelitis is characterized by a sudden 
rise in temperature, with a dull pain in the lumbar 
region, increased frequency of micturition, the urine 
being thick and cloudy and acid in reaction ; in some 
cases it becomes rapidly suppressed. 

Prognosis. — Acute secondary or ascending pyelitis 
usually results in death unless the offending organ is 
removed ; many cases of the acute variety pass un- 
recognized. 

Chronic secondary pyelitis has few clinical symptoms ; 
it probably accompanies nearly all chronic diseases of 
the urinary tract, and its symptoms will depend upon 
the severity and duration of the vesico-urethral ob- 
struction. 



I50 PYELITIS. 

Many recover without surgical interference, but it 
must be remembered that while a case of secondary 
pyelitis may remain apparently in a quiescent state for 
years, suddenly, without any apparent cause, an acute 
pyelitis develops, recognized by the chill, fever, thirst, 
vomiting, extreme pain in the lumbar region, etc., and 
is followed by death in a few hours or days. 

Treatment. — In acute cases, Aconite, Veratrum 
viride, Belladonna, Rhus toxicodendron, Cantharides, 
Cannabis sativa, or Bryonia alba may be indicated; in the 
more chronic cases, where there is an excessive catarrh 
of the mucous membrane of the pelvis, Chimaphila 
umbellata, Berberis vulgaris, Pareira brava, Uva ursi, 
Benzoicum acidum, Sulphur, Pulsatilla, Buchu, Sepia, 
Hydrastinin sulphuricum and muriaticum, Stigmata 
maidis, etc., will be required, according to their special 
indications. See Chapters XXX. and XL. 

In acute primary pyelitis, the remedies appli- 
cable to the general condition will be all that will 
be required. Ill-advised treatment or an unneces- 
sary examination has not infrequently rekindled a 
latent tubercular or other inflammatory condition, pro- 
ducing an acute ascending pyelitis, suppression of the 
urine and death. Hence, in suspicious cases, the first 
examination with instruments should be made only 
after forty-eight hours' rest in bed, with general inter- 
nal disinfection of the urinary tract by the adminis- 
tration of Boric acid, Oil of Eucalytus, Benzoate of 
Soda, Salol or Napthol, in physiological doses. 

In acute pyelitis, the patient must remain in bed, 



PYELITIS. I 5 I 

and hot poultices or fomentations applied to the kidney 
region. Dry cups are sometimes required. Foot 
baths, hot air baths or general hot baths are recom- 
mended. Milk is the ideal diet. Stimulating and 
irritating food must be avoided. In acute primary 
tubercular pyelitis, a nephrectomy is always indicated, 
and it is sometimes necessary in the acute ascending 
variety. In the chronic forms due to obstruction, 
surgical relief will be required only when of tuber- 
cular or lithsemic origin. Drainage of the bladder by 
perineal section is frequently of great benefit. The 
treatment by distilled and alkaline mineral waters or 
Boric acid in doses of ten grains three times daily ; 
Salol, five grains after each meal ; or Saccharin, three 
times a day, must not be forgotten. When the disease 
is caused by calculi the administration of Hydrangea, 
Lycopodium, Silicea or Piperazine for the uric acid 
form, and Magnesium boro-citrate when from the phos- 
phates and oxalates, has often caused the disappearance 
of the symptoms. If the calculi are not dissolved and 
the indicated remedy fails to give relief, a nephrotomy 
must be performed if the condition of the patient 
permits it ; if an abscess has formed and points an 
operation should be made at once. First withdraw 
some of the pus with the aspirating needle, then open 
freely and dress antiseptically. In this operation there 
is no danger of perforating the peritoneum, as the 
kidney is outside and behind it. 

Kelly, of John Hopkins' Hospital, reports the suc- 
cessful treatment and cure of pyelitis by douching the 



152 PYELITIS. 

pelvis of the kidney after catheterization of the ure- 
ter, nsing the nsnal Boric acid, Nitrate of Silver or 
Bi-chloride solntions. After introducing the uretral 
catheter, he uses suction by means of a syringe to 
draw down the thick pus, small calculi, etc., from 
the pelvis of the kidney before using the pelvic 
douche. 



CHAPTER XXII. 
Albuminuria. 

Within recent years the subject of albuminuria 
has received special consideration : some observers 
have asserted that a physiological or natural albu- 
minuria sometimes existed, dependent upon a per- 
verted function of the sympathetic nerves, but the 
researches made by numerous profound investigators 
apparently demonstrate that albuminuria always in- 
dicates the presence of a pathological lesion, transitory 
or permanent, of some part of the genito-urinary 
tract. 

Post-mortem examinations of the kidneys, where 
no clinical history has given evidence of renal disease, 
when carefully and minutely conducted, rarely fail 
to demonstrate gross or microscopic lesions. Hence, 
who can say that the so-called functional physiological 
or transitory albuminuria in a given case is not due 
to some of these insignificant pathological lesions 
which, under ordinary conditions, give no clinical evi- 
dence of their existence. 

The albuminuria of renal origin has received proper 
consideration in the various chapters of this book, 
and the pathological lesions causing many so-called 
functional or physiological albuminuria demonstrated, 
together with some of those of extrarenal origin. 

The extrarenal causes of the presence of albumen 



I 5 4 ALBUM [NUBIA. 

in the urine are legion, and must always receive care- 
ful consideration in formulating the prognosis of any 
given case. In lithaemic or oxaluric conditions the 
crystals of uric acid or oxalate of lime sometimes 
irritate and even scratch the mucous membrane of the 
uropoietic system, exciting an albuminous exudate — 
abrasions, congestions, inflammation of all grades, and 
ulceration of the mucous membrane of the genito- 
urinary tract, cause an albuminous exudate of more 
or less magnitude. In pyuria hsematnria, hsemo- 
globinuria, etc., it can always be demonstrated. 
Another, and very frequently overlooked, cause of al- 
bumen in the urine in the male is the presence of 
the normal or pathological secretions from the prostate 
and seminal vesicles. 'When originating in this man- 
ner it is usually more noticeable in the morning urine ; 
in the female the urine is often contaminated with 
albuminous secretions from the o-enital tract. 



CHAPTER XXIII. 

Bacteriuria. 

Bacteriuria is a condition in which the urine when 
voided contains large numbers of bacteria. This dis- 
ease was first described by Roberts in 1881, and 
later was especially studied by Ultzman. It frequently 
passes unnoticed, or, if recognized, receives but little 
attention. 

Etiology. — Bacteria may enter the bladder either 
from within, from the neighboring organs, or from 
without ; in other words, infection or auto-infection. 
In the majority of cases of bacteriuria, auto -infection 
is the cause, either directly from the intestines, by 
contiguity or indirectly by absorption of the bacteria 
from the intestines and carried by the circulation and 
allowed to percolate through the kidney tissue with the 
urine. (The experiments of Baumgarten and others 
have proved beyond question that the kidneys have 
the power or physiological action to excrete micro- 
organisms.) Bacteriuria is believed to occur frequently 
when from any cause there is an abrasion of the 
mucous membrane of the rectum or intestines. In 
the direct manner, by contiguity of tissue, it may oc- 
cur through the perforation of a prostatic abscess, 
either into both the rectum and urethra or into the 
rectum alone. In either way the bacteria reach the 
posterior urethra and then travel back to the bladder. 



I56 BACTERIURIA. 

In bacterial vesiculitis the bacilli coli commune some- 
times pass into the bladder by direct communi- 
cation, or they may contaminate the urine as it 
passes through the prostatic urethra. They may 
also travel back from the urethra, when origi- 
nating there, into the bladder : a few find their 
way into the urinary stream from the lymphatics 
which have absorbed them in the intestines. Direct 
infection through the urethra may be earned by un- 
clean instruments or where the canal previous to 
instrumentation has contained a bacterial nidus. Bac- 
teria are sometimes inhaled and eliminated by the 
kidneys, as demonstrated by the urine of medical 
students when engaged in dissecting. This condition 
has also been frequently met with in chronic malaria. 

Pathological Anatomy. — This disease is noted in 
uncomplicated cases for the continued healthy condi- 
tion of the mucous membrane of the urinary tract, 
though patients suffering with bacteriuria are especially 
liable to cystitis if exposed to unfavorable influences. 

Clinical History. — The symptomatic history is 
very meagre. The urine when voided is exceedingly 
offensive, opalescent and cloudy. This cloudiness is 
not changed by boiling, acidulation, or filtration with 
the ordinary filter paper : but if a Pasteur filter is 
used, the urine becomes clear ; it may also be 
cleared by shaking it with calcined magnesia or car- 
bonate of barium before filtration. The urine is al- 
ways acid or neutral in reaction, never alkaline unless 
associated with some other condition. The bacteria 



BACTERIURIA. I 5 7 

and cocci are essentially those of intestinal fermenta- 
tion. The bacilli coli commune predominate. The 
microscopic investigation can be made by adding a 
drop of aniline violet to a drop of urine on a glass 
slide ; pass it slowly over an alcohol flame once 
or twice and allow it to cool, and then examine with 
an oil-immersion lens. 

Bacteriuria is frequently associated with disease of 
the seminal vesicles and prostate. In my experience 
both sexes are about equally affected. It is very 
liable to recur, and is only cured by perseverance, 
careful therapy and hygiene. 

Treatment. — The remedies most frequently in- 
dicated are Nitric, Muriatic or Benzoic acids ; physio- 
logically, Salol, Naphtalin, Salicylic acid, Oil of Winter- 
green or Eucalyptus have been given with marked 
benefit. When the bacteria have been introduced 
from without, the various antiseptic douches used for 
the urethra and bladder will be required, and may be 
all sufficient ; these are Potassium permanganate one 
to two thousand to one to ten thousand, Argentum 
nitricum one to four thousand to one to sixteen thou- 
sand, Hydrargyri bi-chloride one to ten thousand to 
one to twenty thousand, Carbolic acid one to five 
hundred, normal Quinine sulphate one grain to the 
ounce, or Borolyptol one part to four to eight of warm 
water. To remove all of the residual bacterial urine, 
the bladder should be catheterized every three hours 
for several days. In many cases good results are only 
procured when for some time the bladder is washed 



I58 BACTERIURIA. 

thrice daily after catheterization. When Bacteri- 
uria is the result of lesions in the mucous membrane 
of the rectum or intestines, flushing of the rectum and 
colon with two quarts of soap and water night and 
morning has materially assisted in the cure of these 
cases, by removing and reducing the number of bacteria 
in the intestines. In all obscure cases the seminal 
vesicles must be interrogated and if diseased must re- 
ceive proper treatment. 



CHAPTER XXIV. 
Chyluria. 

This name has been given to a condition of the 
urine when it presents a milky or opalescent appear- 
ance due to the presence of minute particles of fat 
in suspension. 

Etiology. — It is caused by a parasite called the 
rilaria sanguinis hominis, which is about one-seventieth 
of an inch in length, and the diameter of a red blood 
corpuscle, they are found in the blood stream. 
The larger worm, the filaria Bancrofti, is occasionally 
found in the lymphatics, and causes obstruction in 
the thoracic duct. There is also a non-parasitic form 
of the disease, caused by the obstruction of the 
thoracic duct in some other manner. 

Clinical History. — This disease is endemic in the 
East and West Indies, Brazil, Cuba, China, Aus- 
tralia, and most tropical and sub-tropical climates. 
It is occasionally met with in the temperate zone, 
in those who have contracted it abroad, or have 
been poisoned by mosquitoes which were brought in 
ship cargoes from these infected regions. In the 
parasitic form the disease is due to the blocking of 
the lymphatics by minute micro-organisms, causing 
the contents of the lacteals and intestinal absorb- 
ents to escape through some accidental urinary or 
lymphatic communication. The filiaria sanguinis 
hominis are peculiar, in the fact that they can be 
found in the chyliferous urine at any time, but 



1 60 CHYLURIA. 

more particularly after eating. In the blood, how- 
ever, they are found only during the night or sleeping 
hours. It is said that the blood of one in every ten 
Chinamen contains these micro-organisms, but they 
produce no symptoms unless the parasite becomes dis- 
eased, when the general health will suffer. There is 
progressive debility, lassitude, emaciation, etc., though 
the patients usually die from some intercurrent dis- 
ease. The urine is characteristic, but at times all 
evidence of its chyliferous character will disappear 
for months or years ; the urine is opalescent, and, 
at times, has a reddish cast, from the admixture of 
blood corpuscles. Its specific gravity varies from 
1,007 to 1,020; from 80 to 100 ounces of urine 
are voided daily, the increase being probably due to 
the addition of the chyle and lymphatic products. 
The amount of fat varies from 2-10 to 2 per cent. ; 
it increases after meals, exercise, and sometimes varies 
with the position of the body. When the urine is 
allowed to stand it behaves something like blood, 
thickening, and then separating into a semi-solid and 
a fluid portion ; the micro-organisms are found 
in the coagulum ; the urine has the odor of whey, 
and contains albumen, fibrin, and blood corpuscles. 

Sometimes chyliferous urine coagulates in the pelvis 
of the kidney and the bladder, causing nephritic colic 
and cystitis; when this occurs, a catheter must be intro- 
duced into the bladder, and a solution of Sodium bi- 
carbonate freely introduced to break up the mass, and 
facilitate its discharge. 



CHAPTER XXV. 
Cystinuria. 

This is a rare disease; its chief interest centers in 
the fact that it is the cause of the cystin calculi. 

Etiology. — The latest researches point to a rela- 
tionship between cystinuria and a micro-organism of 
intestinal origin. 

Clinical History. — The urine may contain cystin 
intermittently for years without producing any special 
impairment of the health. The urine, when voided, 
has an odor resembling Orris root ; it decomposes 
rapidly and, on standing, a greasy scum forms on its 
surface : the fresh urine has a yellow-green color and 
mav be acid or neutral in reaction. 



CHAPTER XXVI. 
Hematuria. 

Blood, alone or combined with other foreign pro- 
ducts, sometimes appears in the urine, and constitutes a 
condition described as hematuria. It may be derived 
from any part of the genito-urinary tract and may depend 
upon disease, follow an injury or the administration 
of certain drugs, i. e., Quinine, Turpentine, etc. 
When the blood is from the kidney it is thoroughly 
mixed with the urine, the percentage of albumen is 
larger than would be expected, and contains blood 
corpuscles and sometimes casts : the clots are rounded 
and compressed to the size of the ureter. When the 
blood is from the bladder the clots are very large and 
irregular, and the relative percentage of blood in the 
urine increases as the bladder empties itself. When 
the blood is from the prostatic portion of the urethra 
the clots are leech-like or ovoid in form ; and the per- 
centage of blood is usually greatest at the commence- 
ment of the act of micturition; when the hemorrhage 
from the prostatic urethra is profuse it may, between 
the acts of urination, pass back into the bladder 
and become mixed with the urine. In other cases 
there will be only a drop of blood expelled at the 
end of the act. When the blood is from the 
urethra the clots assume the shape of this canal, 
and blood may ooze from the meatus between the 



HEMATURIA. 163 

acts of micturition. The exact location of the hemor- 
rhage along the urinary tract must be differentiated 
by the urethroscope, cystoscope and the clinical his- 
tory. 

Treatment. — Cantharides. Hematuria of inflamma- 
tory origin with vesical tenesmus. 

Crotalus horridus. Hematuria from blood degenera- 
tion, the urinary deposit looking like charred straw 
and contains degenerated blood cells and fibrin. 

Equisetum Injemcde. Hematuria and slight tenesmus, 
with tenderness and soreness over the region of the 
bladder, not relieved by urination. 

Ipecacuanha. Hematuria, blood from the kidneys, 
accompanied by nausea, oppression of the chest, cutting 
pain in the abdomen and hard breathing. 

Laches is. Hematuria, the urine looks black, and is 
the result of blood degeneration. 

Nux vomica. Haematuria with frequent and painful 
micturition. 

Terebinth. Hematuria, urine smoky, turbid, with a 
sediment like coffee grounds. 

ThJasjn bursa pastoris. Hematuria, blood bright or 
of dark color, urine also containing uric acid crystals 
and pus. The quantity of blood is increased by motion 
and is accompanied with pain in the kidney region. 



CHAPTER XXVII. 
Oxaluria. 

Etiology. — Whenever there is continuously an abun- 
dance of the oxalate of lime crystals in the urine, we 
have a condition which is designated as oxaluria, first 
described by Grolding Bird in 1842. This name 
should, however, not be used unless the oxalate crystals 
are present in abundance, as they are normally found 
in the urine, and are slightly increased after the in- 
gestion of certain foods. The urine is usually slightly 
clouded by mucus, and the crystals are, as a rule, only 
noticed on microscopical examination. 

Clinical History. — There are two varieties of 
oxaluria. In the first class the urine is concentrated, 
dark in color, over- acid in reaction and of high specific 
gravity, due to the abundance of uric acid and urates; 
the patients are hypochondriacal, melancholy, sleepless 
and deficient in mental vigor; there is also digestive 
disturbances with imperfect assimilation of food, flatu- 
lence, loss of strength and great emaciation accompanied 
by neuralgic pains in various parts of the body. In 
the second class the urine has the same characteristics, 
the neuralgic pains are more marked, especially in the 
back and in the extremities, with great loss of strength, 
but without emaciation as in the former variety, and 
boils and small abscesses develop in various parts 
of the body. 



OXALURIA. 165 

Treatment. — The remedies most frequently indi- 
cated are Nitro-muriatic acid, Senna, Oxalic acid and 
Berberis vulgaris. 

The diet must be carefully regulated, composed 
of stale bread, food rich in phosphates, as fish roe, 
calves' and sheeps' brains, Hudson's food, etc. An 
absolute beef and hot water diet has been of the great- 
est advantage, and many have been cured by it alone. 
Sugar, tea and coffee should be interdicted, as well 
as vegetables and drugs containing an abundance of 
oxalates. Alcohol, as a rule, should be avoided; when 
stimulants are required, brandy, whiskey, red wine and 
bitter ale may be allowed. Hard water must never 
be drank, but soft or distilled water should be advised. 
A residence in the mountains or at the seaside, accord- 
ing to the individuality of the patient, should be 
recommended. 



CHAPTER XX VIII. 
Phosphaturia. 

This condition has been divided into three classes : 

True phosphaturia is a persistent and abnormal in- 
crease in the earthy and alkaline phosphates of a 
sterile urine. 

Functional phosphaturia is a transitory deposit of 
earthy phosphates, which sometimes occurs in the weakly. 
The urine may be acid or alkaline, the daily quantity 
of phosphates excreted in the urine being normal in 
amount. 

Secondary phosphaturia is dependent upon a catarrhal 
affection of the urinary tract, the urea in the urine 
breaking up chemically and the resultant carbonate 
of ammonia combines with the magnesian phosphates 
in the urine to form the ammoniaco-magnesian phos- 
phates. 

True phosphaturia. 

Etiology. — Phosphaturia is produced by some 
general condition which causes increased metamorphosis 
of the nerve matter, or by a change in the nutrition 
due to irritation of the nerve centres ; it also precedes 
or accompanies debilitating types of disease, as tuber- 
culosis, cancer, diabetes, etc. 

Clinical History. — In this form the quantity 
of phosphoric acid daily eliminated by the kid- 
neys is increased to some extent over the normal 



PHOSPH ATURIA. I 6 7 

amount and varies with the cause and duration 
of the phosphaturia. The quantity of urine daily 
secreted is augmented, micturition is increased in 
frequency, accompanied by a little vesical irritability. 
The urine may be acid or alkaline in reaction ; the 
patients are hypochondriacal, irritable and emotional. 
Vertigo is sometimes complained of, with numbness 
and weariness in the limbs and back. The gait is 
unsteady, the hands tremble, the tongue is pale and 
flabby, and constipation is usually present. 

Functional phosphaturia. 

Etiology. — Functional phosphaturia is caused by 
the ingestion of sugar, of over-acid fruits, champagne, 
etc.; it is also the result of over-indulgence in venery 
and perverted sexual habits. 

Clinical History. — In this form there is no excess 
of phosphates, but the alkaline condition of the urine 
causes the normal and amorphous phosphates to deposit, 
producing a turbidity. 

Beyond this turbidity of the urine there are but few 
symptoms, except a slight depression of spirits and the 
poor assimilation of food. 

Secondary phosphaturia is the result of a deposit of the 
phosphates in the urine, due to their combination with 
the urate of ammonia, caused by inflammatory changes in 
the bladder or pelvis of the kidney. The phosphates 
may be discharged with the urine as white masses 
mixed with mucus, or they may be deposited on the 
inflamed mucous membrane. 

Treatment. — Phosphoric acid in the potencies has 



1 68 PHOSPHATURIA. 

given excellent results in both the functional and true 
phosphaturia. When of the secondary variety, the 
treatment will call for remedies indicated by the catar- 
rhal condition which causes it. 



CHAPTER XXIX. 
Pyuria, 

Pus, derived from any part of the genito -urinary 
tract, is frequently found in the urine ; this condition 
is called pyuria. Whenever pus is present, albumen 
will be found in a relative proportion. 

When the pus is the result of kidney suppuration, 
the relative quantity of albumen will be large, casts 
are frequently present and the urine may be acid or 
alkaline in reaction. If it is acid, the deposit will be 
flocculent; if alkaline, it wall be ropy. When the pus 
is from the pelvis of the kidney, the urine will usually be 
acid in reaction and contain a flocculent deposit ; it may 
be alkaline and pus plugs and tailed epithelium will be 
discovered with the microcsope. When the pus is 
from the bladder, the urinary sediment will be thick 
and ropy, the reaction alkaline, and the urine will 
contain large numbers of triple phosphates, bacteria, 
bladder epithelia and swollen pus corpuscles and the 
last few drops of urine voided will be very turbid. 
When the pus is from the prostatic portion of the 
urethra, the urine will be acid in reaction, the pus 
sediment will be shreddy and frequently streaked 
with blood ; the first portion of the urine passed will 
be cloudy and the latter portion may be clear and 
micturition is usually painful. When the pus is of 
urethral origin, it will usually be noticed oozing from 



1 70 PYURIA. 

the meatus between the acts of micturition and the 
last portion of the urine may be clear and free from 
pus, and always acid in reaction. 
Treatment. — Varies with the cause. 



CHAPTER XXX. 
Polyuria. 

This is defined as a condition in which there is an 
abnormal secretion of urine of low specific gravity, 
free from sugar and albumen, and accompanied with 
great thirst. 

Willis divides the excessive secretion of urine into 
two groups : hydruria, in which the solid matters 
are deficient, and azotnria, in which there is an excess 
of urea. Fenwick believes that polyuria may be of 
both renal and extrarenal origin. He lays great stress 
on the fact of the persistent or transitory nature of 
the excess. His table gives the causes of polyuria 
and is as follows : 

No sugar, but extreme ) r^. , , . . .-, 

& > Diabetes insipidus, 

thirst; urea increased. ) 

.„ . , , { Chronic Brisht's disease, such as gran- 
Albumen -with casts, but . , . , , . n , . , 
Persistent . . ., ' J ular kidnev, amyloid kidnev and 
. , without pus or residual s ■> -,'<.-, ,.,..- 
excess ot < . advanced scrotulous or syphilitic ar- 
unne. „ . 

(^ lections. 



urine. 



No albumen, but with I 



f Back renal pressure, from uretral twist 
or prostatic atony, or direct renal 



residual urine. 

I irritation of prostatic origin. 

From sexual excesses or debility, without inflammation. 
Transient excess 

of urine, usual- < Dietetic idosyncrasy — i. e., tea, beer, etc. 



ly diurnal. 



Hypochondriasis, hysteria, nervousness. 



Treatment. — Nocturnal and diurnal polyuria, Scilla 
maritima ; nocturnal polyuria, Phosphoric acid ; diurnal 



I 72 POLYURIA. 

polyuria, Ignatia amara, Murex purpurea. When from 
high arterial tension, Grlonoine; from interstitial ne- 
phritis, Nitric acid. Diet and hygiene will depend 
upon the cause, etc. 



CHAPTER XXXI. 
Renal Calculi. 

Etiology. — Renal calculi may be caused by an 
excess of the solid matters of the urine, or by the 
deposit of certain inorganic salts, the products of in- 
flammatory conditions. In the first class are placed 
uric acid, the urates, oxalate of lime, carbonate of lime, 
cystin, etc. In the second, ammoniaco-magnesian 
phosphates and phosphate of lime. 

The urates, oxalates, phosphates, etc., are the re- 
sult of over-concentration of the urine from dyspepsia, 
the ingestion of sweet wines, malted liquors, over-indul- 
gence at the table with lack of exercise, an over-acid 
condition of the system, lithsemia, etc. In many, 
starch, sugar, or a diet of fatty food tend to the 
over-production of solid matter in the urine. The 
absence of salt in the food predisposes to this con- 
dition, i. e.j salt makes the uric acid more solvent ; it 
also increases thirst, and insures a better daily flush- 
ing of the kidneys. Sexual disorders favor this con- 
dition, and age seems to have a special predilection. 
The statistics of Sir Henry Thompson show that in 
1,827 operations performed by him for the removal 
of kidney stone 1,158 were on patients under 25 
years; 1,001 under 15 years of age; from 25 to 
35 there were 231 cases ; and from 25 to 55, 
303 cases, thus placing their greatest frequency of 



I 74 RENAL CALCULI. 

occurrence during the period of adolescence, un- 
doubtedly engendered by the marked acid quality 
of the urine, as well as the frequent feverish con- 
ditions and low vitality so common at this period of 
life. Cadge has stated that the prevalence of renal 
stone in children is due to improper diet and an 
insufficient quantity of milk, and says that it will 
prevail in proportion as solid or artificial foods are 
administered. In youth we find the calculi largely 
composed of uric acid and urates ; in middle life, ot 
oxalate of lime ; while in advanced life they are 
composed largely of ammoniaco-magnesian phosphates. 

The condition of the drinking water of the neigh- 
borhood has a decided influence in the frequency of 
development of renal calculi. Hard water has a 
marked tendency to increase their occurrence and 
in neighborhoods where renal stone seems to be en- 
demic, a change in the drinking water has resulted 
in a diminution of the number of stone cases. At- 
mospheric conditions and the quality of the soil and 
sub-soil, have no special influence on the production of 
the disease. As the female sex is less liable to ex- 
posure, etc., they are proportionately less liable to 
renal calculi. 

Clinical History. — Renal calculi vary greatly, 
from a microscopic condition to those of considerable 
size. They may be round, smooth, rough or ir- 
regular, consisting of a primary pure specimen, as of 
uric acid, oxalate of lime, or composed of two or 
more primary elements, or a third variety, in which 



RENAL CALCULI. I 75 

layers of all, or many, primary elements may con- 
tribute to its formation. Uric acid calculi are the 
most common. They may be yellow, brown or 
black, varying greatly in size, and present a rounded, 
smooth, or facetted surface. When fractured they 
have a crystalline appearance, and may appear 
laminated. The oxalate of lime variety are less fre- 
quent and are usually of a dark-brown color; their 
surfaces are hard and rough, but may be small and 
smooth ; they are frequently associated with a uric-acid 
formation. 

Cy stin calculi are yellow in color, changing to 
green on exposure. They are translucent, and on 
section give some degree of radiation in structure. 
Xanthin calculi have the color of cinnamon. In- 
digo calculi are bluish-black ; one was found by 
Ord, in the substance of a sarcomatous kidney. 
Phosphate of lime calculi are whitish, chalky, 
and vary in size. Carbonate of lime calculi are yel- 
lowish, gray or brown, hard and smooth. Sodium 
urates are soft and small. Urostealith consists of 
cholesterin, fat and uric acid; it is soft and greasy 
to the touch. 

The formation of renal calculi is believed to be 
due to the presence of a colloid substance in the 
urine, which cements the molecular masses together. 
Reindfleisch says that the epithelial cells, with which 
the straight tubes are lined, generate a colloid ma- 
terial in their protoplasm. It is well known that in 
cases of renal calculi, in their early history, before 



I 76 RENAL CALCULI. 

other symptoms are present, that there is found 
a considerable increase of the mucus in the urine ; 
it has also been noticed that the calculi are 
usually covered with a colloid substance or mucus, 
which is difficult to remove. 

The symptoms of renal calculi vary greatly with 
their size, number, character and location ; they may 
be situated beneath the capsule, imbedded in the 
cortex, in the parenchyma or calices of the pyramids, 
or found loose or encapsulated in some part of the 
pelvis of the kidney. They may give rise to the con- 
dition ordinarily spoken of as gravel; if expelled, they 
cause renal colic during their passage, and if retained 
in the kidney or its pelvis, they may produce calculous 
pyelitis and death. There may be absolutely no ob- 
jective or subjective symptoms. 

Pain in the kidney region is the most constant 
symptom. When the calculus is situated in the cortex 
there is a continuous severe fixed pain, or some un- 
easiness and soreness, aggravated by motion, and 
relieved by reclining or sleeping on the side of the 
diseased kidney, the pain being again felt when turning 
to the opposite side. A calculus, imbedded in the 
cortex of the kidney, may never cause pain or any 
change in the character of the urine voided. When 
the calculus is loose in the pelvic cavity it causes 
colic, with pain radiating to neighboring parts, which 
is often accompanied by severe bladder symptoms, the 
patient finding relief from the pain only by reclining 
and sleeping on the unaffected side. Within a year 



RENAL CALCULI. I 77 

or so after the advent of the pelvic stone, pus, etc., will 
usually be present in the urine. When the cal- 
culus is situated in the parenchyma of the kidney, 
the symptoms will assume somewhat the character 
of the cortical or pelvic variety, according to loca- 
tion, etc. 

The pain produced by a renal calculus may resemble 
that occurring in lumbago, and it may be present only 
when deep pressure is applied over the parts. Blood in 
the urine in variable quantities is a common symptom. 
It is generally produced by the irritation of the mu- 
cous membrane of the pelvis of the kidney by the 
calculus. In time a pyelitis is established and pus 
appears in the urine. 

The quantity of blood is increased by motion, and 
especially by carriage-riding ; the urine is acid in re- 
action, thus differing from the history when a cal- 
culus is present in the bladder, where carriage-riding 
does not increase the quantity of blood and the 
urine is alkaline in reaction. It must be remembered, 
however, that, in the chronic form of calculous pyelitis, 
the urine may be alkaline and may be accompanied 
by uraemia or hectic fever. Acute hydronephrosis 
may at any time develop from the obstruction of the 
ureter, by a calculus from the kidney. An increase 
in the amount of mucus and the density of the urine even 
when blood and pus are absent, are considered diag- 
nostic evidence of the presence of a renal calculus. When 
an abundant shower of microscopic calculi arc dis- 
charged, we have a condition called gravel, which pro- 



178 RENAL CALCULI. 

duces smarting and burning on micturition, with irrita- 
tion and congestion of the urinary tract, pain and un- 
easiness, referred to the sacroiliac region, which shoots 
down the course of the ureter, together with irritation 
at the neck of the bladder, headache, flatulence, malaise, 
etc. An over-acid and concentrated urine alone may 
keep up a long train of symptoms and finally causes 
or terminates in pyelitis, cystitis, etc. 

Treatment. — When the urine is acid the remedy 
may be Nitro-muriatic acid. Nitric acid, Xux vomica, 
Pulsatilla, Sulphur, Benzoic acid, Lycopodium, Sepia, 
Magnesium boro-citrate, Quinia sulphate or Sarsaparilla, 
and when alkaline, Phosphoric acid, Phosphorus or 
Magnesia phosphorica. For symptomatology see Chap- 
ters XXXII. and XL. 

Reduce the quantity of meat and increase the aver- 
age amount of vegetables. Light meals must be the 
rule. 

Prohibit the use of champagne, sweet and new wines, 
malted and spirituous liquors. Sedentary habits must be 
abandoned and out-door exercise gradually encouraged 
and continued. Frequent bathing and Turkish or Russian 
baths are beneficial. Massage once or twice weekly 
and frequent rubbing with a rough bath towel or 
flesh brush are productive of much good and more 
especially daily massage of the afTected side. Sexual 
hygiene is important, especially in the young. 

A pint of Piperazin water should be drank daily in 
divided doses ; it is prepared as follows : 



RENAL CALCULI. I 79 

R Piperazin, 5yss. 

Aqua Destil., 5V. 

M. 

Sig. Tablespoonful to a pint of any mineral water. 

Imported Vichy, Ems, Carlsbad, Bedford, Staf- 
ford, Contrexeville, Poland, etc., or distilled water in 
large quantities should be advised, and the alkaline 
flow of urine, which occurs usually about 10.30 a. m., 
if absent, should be re-established and maintained. 
When the alkaline waters do not produce the desired 
results, thirty grains of Citrate of Potash, well diluted 
with water, may be administered at bed time and 
between meals. If the calculus is large, alkaline 
waters tend to increase its size, therefore they are only 
indicated early in the case. 

An alkaline condition of the urine prevents the 
deposit of the solid matters in the urinary tract, while 
acidity facilitates it. Whenever the urine for any 
length of time remains acid for the entire day it 
indicates over-acidity and concentration. These con- 
ditions may give rise to many, if not all, of the 
symptoms of gravel and neuralgia of the kidneys. 

If continued and careful treatment does not remove 
all the symptoms, surgical relief will be required. 

Before the exploratory examination or operation, 
the ureter should be catheterized, by the Caspar 
method in the male and Kelly's method in the female, 
and a proper examination of the urine made. In the 
female Kelly's wax-covered probes may be introduced 



l8o RENAL CALCULI. 

into the ureter to ascertain if there is evidence of a cal- 
culus in the ureter or pelvis of the kidney. If a calculus 
is present, marked indentations will appear on the 
wax-covered end of the probe ; the soft renal tissues 
make no indentation. 



CHAPTER XXXII. 
Renal Colic. 

This is caused by the passage of a renal calculus, 
a hydatid, or a clot of blood or pus through the 
ureter, the pain varying greatly in severity and dura- 
tion, according to the condition of the ureter and the 
size and form of the foreign body. 

Clinical History. — Renal colic may be moderate 
or severe, continuing only a few minutes, or it may 
be agonizing and last for hours or days; sometimes it 
is intermittent in character. It commences suddenly, 
although it may be preceded by some pain and un- 
easiness which is referred to the lumbar region of 
the affected side ; it ends almost as suddenly when 
the foreign body enters the bladder. 

When the foreign body engages at the opening of 
the ureter in the pelvis of the kidney it causes pain 
which is referred to the affected side. If, on the 
other hand, it becomes disengaged and passes back 
into the pelvis of the kidney the pain will cease for 
the time being, to return when it re-enters the ureter. 

The pain usually commences suddenly, increases 
in violence, follows the course of the ureter and 
shoots clown the inner side of the thigh, to the 
end of the penis and into the scrotum which is fre- 
quently retracted by the contraction of the cremaster 
muscle. The pain may radiate in various directions 



I 82 EEXAL COLIC. 

over the abdomen to the breast or up the back ; it 
is paroxysmal, and so agonizing at times that it often, 
in nervous people, causes convulsions or syncope. As 
the attack increases in violence the patient rolls and 
twists from side to side and from one position to an- 
other in the endeavor to find relief. The face becomes 
pale, anxious, covered with perspiration, and the suffer- 
ing is so great that they frequently scream and moan 
like a woman in labor. The pain continues between 
the paroxysms, but is less severe. There is an in- 
effectual desire to urinate, which is accompanied by 
burning, the urine being small in quantity and of dark 
color. Vomiting is of frequent occurrence. TVnen 
the pain is very severe there may be rectal tenesmus 
together with frequent unsatisfactory stools. Unless 
the pain continues for some time there is usually no 
rise in temperature nor change in the pulse. If the 
foreign body becomes impacted in the ureter the 
intense pain may gradually subside and asume a gnaw- 
ing character. This may disappear if the ureter en- 
larges to allow the urine to pass alongside the 
foreign body, but when it entirely occludes the ureter 
it leads to hydro- or pyonephrosis. 

After passing into the bladder the calculus is usually 
expelled with the flow of urine during the next few 
hours; it may have caused great pain when passing 
through the ureter, but. if the urethra is normal, it 
may be voided with the urine without notice or pain. 
In order to ascertain the character of the foreign body 
which caused the colic, the urine must be carefully 






RENAL COLIC. I 83 

examined at each urination until the obstructing body 
is found. 

Prognosis is always good unless impaction occurs, 
causing a hydro- or pyonephrosis, etc. One attack 
predisposes to another. After the attack there is pro- 
fuse micturition, and the urine may contain blood for 
some days. 

Treatment. — Argentum nitricum. Nephralgia from 
the passage of renal calculi or congestion of the 
kidney ; dull aching pain across the back, extending 
into the bladder ; urine burns when voided ; dark 
urine containing uric acid, blood and renal epithelium. 

Berberis vulgaris. Renal colic ; sharp stitching pains 
radiating from the renal region in all directions, par- 
ticularly downward and forward into the pelvis ; sharp 
darting pains along the ureters ; urine has a reddish 
deposit composed of mucus, epithelium and lithiates. 

Cantl tar Ides. Gravel in children, with irritating pain 
extending down into the penis, with constant pulling 
on that organ, also pain and congestion during the 
passage of renal calculi. 

Coccus cacti. Renal colic and hematuria; lancin- 
ating pains extending from the renal region to the 
bladder; urine contains large quantities of brick-red 
sediment, urates, uric acid, etc. 

Dioscorea villosa. Gravel, renal colic, pain shooting 
from kidney to bladder down into the testicles and 
leg, with cold clammy sweat over the body. 

Lycopodium davatum. Dull pain in renal region, 
relieved by micturition ; renal colic, especially of the 



184 RENAL COLIC. 

right side ; urine scanty, high colored ; red, sandy 
deposit composed of urates and uric acid ; urine some- 
times contains mucus and pus, causing a whitish sedi- 
ment. 

Nitric acid. Renal calculi and colic ; the gravel 
is composed mostly of oxalate of lime. 

Nux vomica. Renal colic or gravel; pain extending 
from the renal region into the genital organs or leg, 
usually associated with intense and continuous back- 
ache ; painful, ineffectual desire to urinate ; urine 
passed drop by drop, with burning, tearing pains at 
the neck of the bladder. Acts best on the right side. 

Pareira brava. Renal colic, with pains shooting 
down the legs ; violent pains into the glans penis so 
intense that patient goes down on hands and knees 
to urinate ; urine contains a red sandy deposit with 
much thick white viscid mucus ; urine ammoniacal. 

Picki. Renal colic, lithsemia. 

Stigmata maidis. Renal colic, chronic pyelitis. 

Tabacum. Renal colic with collapse from extreme 
pain. 

Thlaspi bursa pastoris. Renal colic, renal calculi 
with hematuria; urine loaded with red crystals; has 
acted very satisfactorily in uric acid gravel. 

Uva ursi. Renal calculi and pyelitis. 

During the attack of colic, hot baths, sitz or gen- 
eral, hot fomentations or hot water bags placed over 
the seat of pain, give great relief and seemingly facili- 
tate relaxation of the parts and passage of the calculus. 

Alkaline waters in large quantities, Citrate of Potash 



RENAL COLIC. I 85 

in 20-grain doses well dilated, every three hours, and 
light beers have been recommended to increase the 
flow of urine and so force the obstructing body onward. 
Change of position and manipulation of the parts often 
give relief and dislodge the mass. The inhalation of 
Ether or Chloroform speedily alleviate. Supposi- 
tories of Opium and Belladonna are useful and 
act satisfactorily, but many physicians when called ad- 
minister a hypodermic of Morphia (}i to }4 grain 
combined with ylho of a grain of Atropia), the dose 
being regulated according to the intensity of the pain 
and repeated as required, but always, when possible, 
precede it by a large stimulating rectal enema which 
seems to favor the progress of the obstruction. The 
patient usually quiets down, becomes easy or falls 
asleep, to awake free from pain with, possibly, only 
a little soreness of the parts. 

With some, however, the use of Morphia is followed 
by many unpleasant symptoms, especially so in the 
gouty, and it may be the direct cause of bringing on an 
attack of gout which may be more painful than the 
colic itself. In these and many other cases satisfactory 
results have been obtained by the administration of 
the indicated remedy; relief is not immediate, but 
they escape the attack of gout. The passage of a full- 
sized steel sound into the bladder has been recom- 
mended and used with satisfactory results ; its action 
is probably reflex, causing the ureters to dilate and 
allow the urine behind to push the obstruction into the 
bladder. 



CHAPTER XXXIII. 
Ureteritis. 

Etiology. — Congestion of the ureteral tissue from 
traumatism, the presence of tumors, over-distention from 
any cause, or irritation by the urine, etc., predispose to 
true ureteritis, though it is almost id variably caused by 
infection, either ascending from the bladder by 
gonorrheal extension, descending as in tubercular le- 
sions, hematogenous, or from contiguity of tissue in 
periureteral cellulitis, etc. 

Clinical History. — A true pathognomonic history has 
not as yet been formulated, the symptoms varying with 
the exciting cause and the severity of the inflamma- 
tion. The one symptom that has been recognized is 
tenderness and soreness of the ureteral canal on 
palpation. The inflammatory swelling may greatly en- 
croach upon and reduce the calibre of the canal, and 
if the walls of the ureter are greatly involved, may 
terminate in a strictured condition. 

Treatment. — The remedies are those indicated 
for the cystitis pyelitis, etc., causing it. See Chapter 
XL. The diseased ureter may be catheterized and 
douched with Xitrate of Silver, 1 to 2,000 ; or Perman- 
ganate of Potash, 1 to 5,000, etc., as indicated. In- 
ternal disinfection by physiological doses of Boric 
Acid, Salol, Oil of Eucalyptus, etc., has acted satis- 
factorily. When the disease is an accompaniment of 



URETERITIS. I 8 7 

suppuration, or any other condition of the kidney, re- 
quiring a nephrectomy relief of the symptoms sometimes 
occur only after the ureter as well as the kidney has 
been removed. This is especially true when it is of 
tubercular origin. 



CHAPTER XXXIV. 
Ureteral Obstruction. 

Stricture of the ureter may occur at any point of 
this canal The majority of cases reported have 
been located near the bladder ; all narrowed conditions 
of the ureter are not, however, strictures. This 
canal, which is ten to fifteen inches in length, has three 
normal points of contraction; the first being 1% to 2 
inches from the pelvis of the kidney ; the second at 
the junction of the pelvic and vesical portion, and 
the third at a point where the ureter crosses the iliac 
artery. There are also a number of thin-walled semi- 
lunar valves, situated transversely to the ureter, 
opening upwards, and one or many of them may be- 
come enlarged and obstruct the urinary flow, or re- 
tard the passage of a calculus. Strictures may occur 
at any point along the ureter, caused by cicatri- 
zation of a tubercular ulcer, from ulcerations caused 
by the passage of a calculus and possibly the re- 
sult of an extension of a gonorrheal inflammation. 
The most frequent cause, however, of ureteral ob- 
struction is the lodgment of a calculus in the 
canal, which may completely close the duct. When 
complete, it results in hydro- or pyonephrosis, 
which may finally cause atrophy of the kidney of 
the affected side. When the kidney and ureter of 
the opposite side are in a normal condition, it may 



URETERAL OBSTRUCTION. I 89 

occur without giving rise to any special symptoms. 
It may, however, be suspected, after a renal colic, 
with hematuria, etc., when the pain gradually be- 
comes confined to one point, and the blood in the 
urine does not completely disappear, especially if 
pressure along the ureter gives rise to a pain at 
this special 'fixed point. The kidney of the opposite 
side soon undergoes hypertrophy, and unpleasant 
symptoms are rarely experienced ; but if the ureter 
of the opposite side has been obstructed at some 
time in the past by a calculus, a stricture, or by 
the pressure of new growths, by displacements, or the 
kidney has been incapacitated, removed, or was unde- 
veloped, the symptoms will then assume a very serious 
nature, namely, obstructive suppression of the urine. Sir 
William Roberts says : " When suppression is complete, 
the patient may live from nine to eleven days." Sir 
James Paget records a case of total suppression of 
twenty-one days' duration, w T ith only one day on which 
urine was passed. The suppression may be partial or 
complete, varying with the size and contour of the 
calculus or tumor, etc. If complete, a hydronephrotic 
tumor develops on the side obstructed, giving a slight 
increased fulness to the renal region, uraemia sets in 
and death follows. In some of the cases reported there 
were no symptoms except suppression of the urine fol- 
lowing the renal colic. In all cases of complete suppres- 
sion time is valuable, and a diagnosis must be correctly 
made and surgical relief given at once, or the patient 
will soon die. The ureters should be examined with a 



190 URETERAL OBSTRUCTION. 

Casper's ureter-cystoscope, or by the Kelly method. 
When possible, Kelly's wax probes should be used 
to verify the diagnosis, and the patient should also be 
examined for tumors, displacements, etc. 

Treatment. — For symptomatic treatment see 
Chapter XL. 

Hot fomentations should be applied to the pain- 
ful parts ; hot baths and massage are frequently of 
much benefit ; intra-vesical injections of warm, anti- 
septic solutions have in some cases apparently over- 
distended the lower part of the ureter, and assisted 
the obstruction to pass into the bladder. When 
these methods fail, we must resort to surgical mea- 
sures. First, make a lumbar exploratory incision 
and ascertain if a calculus blocks the opening of 
the ureter at its exit from the pelvis of the kid- 
ney. If this is negative, a nephrolithotomy may 
be indicated, when the ureter should be suitably 
explored with a steel, 4 to 12 F., bulbous bougie 
With this instrument it may be possible to dislodge 
the obstructing calculus, when it may pass down the 
ureter into the bladder ; if not successful in dis- 
lodging the calculus, the surgical treatment will vary to 
suit the individual case. A renal fistula can be es- 
tablished, either through the lumbar region, into the 
vagina, or into one of the small intestines. If one 
ureter only is obstructed, and the other, with its 
kidney, is normal, the question of nephrectomy should 
be considered if such obstruction cannot be removed ; 
if the calculus which causes the obstruction is situ- 



URETERAL OBSTRUCTION. I 9 I 

ated near the bladder opening, it may sometimes be 
discovered by a digital examination through the vaginal 
walls and surgically removed by that route. Again, 
the calculus may project into the bladder, being fixed 
in the ureteral exit, and may be disengaged by the 
Thompson stone searcher, or the end of a cystoscope. 
In ureteral operations, the canal must always be 
opened longitudinally to avoid subsequent stricture. 



CHAPTER XXXV. 
Ureteral Injuries and Fistulae. 

The ureters are situated deep in the abdominal and 
pelvic cavities, and are so well protected by the 
bony and muscular walls behind and the abdominal 
viscera in front that injury can hardly be believed to 
occur without causing instant death. But cases are 
now and then reported of rupture of the ureter, the 
result of violence applied to the front of the body, by 
gunshot wounds or accidentally by the surgeon, also 
by injury to its internal mucous lining by the passage 
of a calculus ; all of which may result in stricture 
and closure of the duct. Rupture of the ureter some- 
times presents no immediate symptoms, in others 
they are masked by the general symptoms or con- 
ditions present. We may expect collapse, hemor- 
rhage into the surrounding parts with extravasation of 
urine, which is usually non-irritant in character, ac- 
companied by the passage of blood-stained urine, etc. 
Rupture of the ureter usually occurs at or near its 
junction with the pelvis of the kidney. When rup- 
ture of the ureter occurs a large quantity of urine, 
deficient in urea, soon accumulates in the cellular tis- 
sues behind the peritoneum, giving rise to a tumor 
on that side of the abdomen which may extend into 
the loin or to the iliac fossa. The fact that this 
effusion of urine into the cellular tissue does not cause 



URETERAL INJURIES AND FISTUL.E. I 93 

suppurative changes is remarkable and deserves special 
notice. Harrison has advanced the theory that rupture 
of the ureter stops the secretive function of the kidney 
and the process of exudation alone is allowed to continue, 
hence, the deficiency of urea and consequently the 
absence of anything to cause ammoniacal decomposi- 
tion. 

In the ureter as in the urethra, traumatic conditions 
tend to stricture, leading to a closure of the duct, 
hydronephrosis, and finally atrophy of the kidney. 
When, however, the injury involves the peritoneum, 
shock, peritonitis and death are not long delayed. 

Ureteral fistulae sometimes occur, opening externally 
into the lumbar region, on the abdomen or in the 
groin, or they may communicate with the rectum, 
bladder, stomach, vagina or uterus. The fistula may 
be direct or irregular in its course. It may be caused 
by ulceration of tubercular or cancerous growths, and 
the presence of calculi or other foreign bodies, but 
it is more commonly the result of gynaecological opera- 
tions. 

In ureteral fistula there is a continuous or inter- 
mittent discharge of urine, which is usually normal 
in character. If the opening in the ureter is near 
the kidney the flow will be continuous ; if near the lower 
extremity of the ureter, it will be intermittent. 

Treatment. — This depends upon the conditions 
present. If the peritoneum is involved, a laparotomy 
and possibly a nephrectomy will be indicated. When 
there is fluid in tbe cellular tissue behind the peri- 



194 URETERAL INJURIES AND FISTULA. 

toneum, its repeated removal with the aspirator has 
acted satisfactorily, and recovery has been rapid ; 
but if there is hemorrhage, a lumbar exploratory in- 
cision must immediately be made, the severed ends of 
the ureter looked for, properly united and the vessels 
ligated. All operations on the ureter above the iliac 
crossing should be retro-peritoneal, except when occur- 
ring during a laparotomy. The pelvic portion may be 
operated upon through the vault of the vagina, the 
rectum or perineum. Surgical operations are also indi- 
cated when, after injury to the ureter, it is believed 
that a stricture has formed, and Kelly's probe proves 
its existence. The latest operation for stricture or 
rupture of the ureter is Van Hook's method of 
ureteral anastomosis ; the ruptured or severed lower 
end is tied with silk or catgut, and a longitudinal 
incision made in the lower segment below the liga- 
ture, and into this is pressed the end of the upper 
segment which may be anchored in with a catgut 
suture. When the ureter is only partially divided, the 
wound should be extended longitudinally and the in- 
cised longitudinal wound sutured transversely, thus 
compensating for anticipated strictured conditions. The 
question of suturing the ureter into an intestine 
has been suggested but has many objections, es- 
pecially that it allows the bacilli coli communes to 
travel back to the kidney, though many good results 
have been reported from this method. Borri, Poly- 
clinico Number 19, 1895, reports many experiments 
on dogs; in two cases, he made a lengthwise in- 



IKiyiT.KAL INJURIES AND FISTULA. I95 

cision in the intestine and connected the ureter with 
it by means of a button (similar to the Murphy's 
button), with a tube inserted into the ureter. The 
buttons came away in from nine to twelve days and 
the experiments were successful. Rydygieu and Van 
Hook advise, in cases when the ureter is cut by 
the surgeon, that both ends of the ureter be 
brought out through the abdominal walls and the 
wound allowed to close about them. When union is 
complete they make an artificial channel of skin to 
connect the open ends, by making parallel incisions 
between the two openings and suturing the isolated 
integument to form a tube : after union has taken 
place along this canal, the ends of the ureter are sutured 
to it and the whole depressed by suturing the skin 
of the two opposite sides over it. 



CHAPTER XXXVI. 
Renal Injuries. 

Traumatism of the kidney is usually uni-lateral. It 
has the advantage over a diseased condition in the fact 
that the other kidney is supposed to be healthy and 
able to do the work of both. These injuries are 
brought about in two ways : either by puncture, gun- 
shot wounds, etc., or by external violence. Incised 
or gun-shot wounds are liable to involve other organs, 
and foreign bodies may be earned into the deeper 
tissues, producing other complications. 

Injuries from external violence may occur without 
breaking the skin, as from blows, falls or the squeez- 
ing of the parts between heavy bodies. When the 
capsule of the kidney is not ruptured the hemor- 
rhage is slight ; when the kidney is ruptured it is 
usually in a transverse direction, rarely longitudinally. 
When occurring with other injuries, it may be over- 
looked. 

Clinical History. — Collapse and shock are usually 
present, accompanied by pain referred to the renal 
region, local hemorrhage and haematuria. When injury 
occurs to the kidney and its appendages, nature often, 
during the collapse, causes plugging of the renal 
artery ; the secretion of urea stops and only a 
watery fluid is exuded with the blood, and, conse- 
Cjuently, destruction of tissue from its presence is rare. 



RENAL INJURIES. I 97 

When the kidney is ruptured, sooner or later there 
occurs a swelling in that region, accompanied by 
a temperature of 103 to 105° F. In some cases the 
traumatism is so slight that pain in the renal region 
and a slight hematuria may constitute the entire clinical 
history. 

Treatment. — The administration of Arnica, Aconite, 
Belladonna, or Veratrum viride as indicated, with rest, 
hot fomentation and stupes are in the lighter cases all 
sufficient. If there is an incised or gun-shot wound 
and evidence of peritoneal involvement, a lapa- 
rotomy should be made, and the kidney removed if 
necessary. If the injury has not involved the peri- 
toneal cavity, the lumbar opening should be in- 
creased in size to allow^ of careful examination, a 
catheter inserted for drainage, and the wound packed 
with iodoform gauze to arrest hemorrhage. When 
fracture of the kidney has occurred, if the peri- 
toneum has not been involved, the kidney should 
be examined through a lumbar exploratory in- 
cision, and the parts unlikely to do well should 
be removed, the wound packed and proper drainage 
provided. In many cases, on account of the liability 
to infection, and on account of the possible formation 
of abscesses and a renal sinus, which are so unsatis- 
factory to treat, it is advisable to remove the kidney. 
If the pelvis of the kidney is ruptured, its edges must, 
if possible, be sutured. We must also remember, in 
this condition, that for some unknown reason anuria 
sometimes develops, even when the opposite kidney 



I98 RENAL INJURIES. 

is healthy. The possibility of there being only one 
kidney should also be considered. If the injured 
kidney is dislocated and can be saved, it should 
always be stitched to the posterior abdominal wall. 



CHAPTER XXXVII. 
Renal Fistulae. 

Etiology. — They may be caused by or follow traum- 
atism and surgical injuries of the kidney, or result 
from the rupture of a pyonephrotic, pyelonephrotic or 
peri nephrotic abscess. 

Renal fistulae of surgical origin are rare, except when 
the pelvis of the kidney is directly opened, unless ne- 
crotic or infected tissues have been involved in 
the operation. They are usually caused by the pres- 
ence of a foreign body, such as a calculus or drainage 
tube, excessive and continued suppuration, incomplete 
drainage, and the continued escape of urine through 
the opening. 

Clinical History. — They have received special 
names according to their point of opening. 

Reno-cutaneous fistulae are generally quite direct, and 
open usually in the lumbar or inguinal region. An 
erythematous patch of integument surrounds the open- 
ing, and from the ulcerated aperture a quantity of pus 
and urine will escape. The fistula is usually tortuous, 
and has thickened and indurated walls. 

Reno-intestinal fistulae usually open into the colon, 
and are characterized by vomiting and purging of pus 
and urine. 

Reno-gastric fistulse are very rare : three cases have 
been reported where renal calculi entered the stomach 



200 RENAL FISTULA. 

by a reno-gastric fistula and were expelled by tlie 
mouth. 

Reno-bronchial fistula? have also occurred. 

Treatment. — Free, direct drainage, when possible, 
is always indicated. If the ureter is or can be made 
pervious ; the usual surgical methods of packing the 
fistulous tract after curetting, will result in granula- 
tion and closure from the bottom, or the walls of the 
fistulous tract can be removed, and the wound closed 
with catgut sutures. If the ureter cannot be ren- 
dered pervious, and the opposite kidney is normal, 
a nephrectomy will be indicated. 



CHAPTER XXXVIII. 
Suppurative Nephritis. 

Etiology. — It may be the result of violence from 
without or originate within the kidney, from irritation 
of a calculus in the substance of the kidney, the break- 
ing down of a tubercular mass, or by extension of inflam- 
mation from neighboring organs ; surgical operations upon 
or in the region of the kidney or genito-urinary tract, 
exposure to wet and cold, infarction, embolism 
from malignant endocarditis or pyaemia, an ascending in- 
fection from the bladder, etc. Von Wunschheim says 
that, 1st, Pyelonephritis is the result, in the great 
majority of cases, of infection by the bacterium coli 
commune ; in a fewer number of cases through the 
proteus, or the more ordinary forms of suppurative 
cocci. 2nd, a certain number of cases in which the 
ordinary pyogenic microbes are the cause of the ir- 
ritation and consecutive pyaemia results. 3rd, pyelo- 
nephritis resulting from irritation of staphylococci and 
streptococci is not to be differentiated from other 
forms alone by the pyaemia present, but also, micro- 
copicaily, by the marked necrosis of tissue and the 
absence of increased inflammatory tissue formation, 
which is produced by the bacterium coli commune. 
4th, it is not probable that the typical ascending 
pyelonephritis can be produced by the passage of 



202 SUPPURATIVE NEPHRITIS. 

micro-organisms from the bladder through the cir- 
culation. 

Pathological Ax atomy. — Suppurative inflammation 
of the kidney may occur idiopathically or it may be 
due to various causes. 

Idiopathic form. From some unknown cause the 
kidney may be the seat of one or more abscesses. 
The abscess may involve the whole of the kidney 
structure, it may be completely enclosed in a dense 
fibrous capsule, probably the thickened capsule of the 
kidney, or it may be connected with one or more 
sinuses which have burrowed into the surrounding 
soft parts. There may be an abscess of considerable 
size involving a part of the kidney, and a number 
of smaller ones, varying in size from that of a pin- 
head to a pea. As a rule, one kidney only is involved. 

Traumatic form. Perforating wounds which have 
involved the kidney tissue or violent blows in the 
lumbar region may be followed by suppuration. The 
inflammation may be diffuse and the whole kidney 
converted into a purulent mass, or one or more cir- 
cumscribed abscesses may be formed. 

Suppurative pyelonephritis. This form of suppurative 
nephritis generally affects both kidneys. The mucous 
membrane of the pelvis is inflamed and covered with 
fibrin and pus. Throughout the kidney are seen 
numerous small abscesses, some of them so minute 
as to be seen only by the microscope. In addition to 
these, there is a diffuse suppurative inflammation. The 
tubes are filled with pus and blood. The stroma is 



SUPPURATIVE NEPHRITIS. 203 

infiltrated with pus cells. The mucous membrane of 
the ureters is often thickened and covered with fibrin 
and pus. Often the inflammatory process can be 
traced to the bladder, thus determining the source of 
infection. 

Abscesses formed by infectious emboli If there is a 
pre-existing malignant endocarditis or pyaemia, small 
infectious emboli may be deposited in the kidney 
structure with the formation of abscesses. 

The whole kidney is enlarged and congested. The 
cut surface is studded with small reddish areas, each 
with a whitish centre. Microscopically these areas 
which surround the abscess are the seat of a diffuse 
inflammation, which results in swelling and death of 
the renal epithelium. Cocci may sometimes be found 
in the abscess cavities. 

Clinical Histoey. — One or both kidneys may be 
involved. It is, however, usually uni-lateral and dis- 
tinct from other renal diseases. It may complicate 
Blight's and other forms of kidney conditions. There 
is some swelling or fullness of the loin on the af- 
fected side with tenderness on deep pressure, but 
the kidney is so deeply seated that it must not be 
expected that fluctuation will be found, nor is it well 
to wait for its appearance before giving surgical relief. 
The temperature, which is remittent . in character, 
often reaches 103° F., and in many cases gives suf- 
ficient evidence of the presence of pus to warrant a 
nephrotomy long before the conclusive physical signs 
appear, and if pus is not found, no harm has been 



204 SUPPURATIVE NEPHRITIS. 

clone. When pus is found, it may be clear and creamy 
or thin, ichorous and very offensive. 

When the abscesses are small they may break down 
and discharge into the pelvis of the kidney, and 
blood and pus will appear in the urine ; they may 
become encapsulated, others burrow into the neigh- 
boring parts and ultimately discharge externally or 
rupture into the peritoneum, pericardium, pleura, etc., 
and cause death by shock. 

Symptoms are rarely perceived during life in in- 
farction caused by emboli from endocarditis, and even 
when the endocarditis is of malignant or septic origin, 
they are masked by the general condition. When 
resulting from mechanical injuries or surgical inter- 
ference, the violent and repeated chill, fever and 
sweat, vomiting and other digestive disturbances, as 
well as pain, swelling, etc., in the region of the in- 
jured or diseased kidney, are marked, and blood and 
pus may appear in the urine. Recovery may take 
place, but many pass into a typhoid state and die. 

If of the ascending variety from cystitis following 
gonorrhoea, stone in the bladder, or following operation 
on the genito-urinary tract, there will be chills, irreg- 
ular rise in temperature and profuse perspiration with 
rapidly developing typhoid conditions. The urine, 
which is diminished or suppressed, will contain blood 
and pus. 

If of bacterial origin, it is almost always fatal. 
When the result of an enlarged prostate, or renal 
calculus, the patient is generally over fifty years 



SUPPURATIVE NEPHRITIS. 205 

of age. The onset of the disease may or may 
not be preceded by urinary symptoms. Chill and 
fever may be absent, but they are usually present 
to a moderate degree. The first symptom may be a 
decrease in the quantity of urine voided, with hem- 
aturia. Symptoms of septicaemia, sub-acute in char- 
acter, soon set in, with anxiety, feeble pulse, etc., 
followed, in a short time, by death. 

Treatment. — Veratrum viride, Arnica, Aconite or 
Belladonna in the beginning are often of decided 
benefit, and in many cases often abort the disease; 
later Hepar sulphur, Hekla lava, Silicea, Sulpho- 
carbolate of soda, etc., will be necessary. Attention 
should be given to the diet, to build up the patient 
and repair the waste going on in the system. Liquid 
peptonoids, somatose, kumyss, matzoon, Hudson's 
food, malted milk, beef peptonoids, clam broth, etc., 
should, therefore, be recommended. Hot fomentations 
and general hot baths are very comforting and useful. 
When pus forms it must be evacuated, and removal of 
the diseased kidney may sometimes be necessary. 
Dr. Weir, Medical Record, Sept. 15, 1895, reports a 
case of surgical kidney of the right side, cured by re- 
moval of the diseased kidney, followed by treatment 
of the chronic urethral trouble, which was the ex- 
citing cause. When the condition of the patient war- 
rants it, he advises an exploratory incision opening up 
the capsules of one or both kidneys, to relieve the 
tension of the renal capsule, and when one only is 
involved, its removal, if indicated. 



CHAPTER XXXIX. 
Renal Surgery. 

P. Wagner, in the Cliir. Beitr., Festschrift fur Bruno 
Schmidt, warns against the too hasty removal of the 
kidney, as experience has proven that the remaining 
kidney frequently does not undergo compensatory 
hypertrophy, consequently it does not do the work of 
both organs, and the patient dies from insufficient 
renal action : he advocates the following rules : 

Nephrorrhaphy for floating kidney, including cases 
of intermittent hydronephrosis due to dislocation of 
the kidney. 

Nephrolithotomy for renal calculi, whether in the 
kidney or its pelvis, in the absence of extensive sup- 
puration or advanced alteration of the kidney sub- 
stance. 

Nephrotomy for pyonephrosis, hydronephrosis, and 
solitary cysts of the kidney or echinococcus cysts. 

Partial resection for benign tumors, localized ab- 
scesses and calculus formation. This operation will prob- 
ably have a much wider application iu the future 
than it has at present. 

Nephrectomy may be necessary either as a primary 
or secondary operation. As a primary operation it 
is indicated for malignant tumors of the kidney or 
its capsule, in tuberculosis, and in abscesses which 
are distributed throughout the whole kidney ; also 



RENAL SURGERY. 207 

in injuries which have badly lacerated' the kidney 
and caused uncontrollable hemorrhage. 

Secondary nephrectomy may become necessary in 
emaciated patients with suspected tuberculosis in 
other organs, whom nephrotomy and tamponade 
have tailed to relieve. In cases of abscess in which 
the integrity of the other kidney is suspected, ne- 
phrotomy is first to be tried ; this failing, the 
kidney should be removed. For a similar reason, 
badly lacerated kidneys whose artery and vein are 
intact, should he sewed, tamponed, or in part resected, 
and nephrectomy be performed only secondarily if 
these measures do not succeed. 

There remain to be considered only pyonephrosis 
and hydronephrosis. Primary nephrectomy in these 
cases deprives the body of the use of some rem- 
nants of active renal tissue, whose loss under cer- 
tain circumstances may mean great danger to the 
patient. Ayer's investigations have shown that a 
hydronephrosis scarcely ever destroys all the se- 
creting tissue. Nephrotomy in such cases can do 
no harm, and statistics show that the resulting fis- 
tulse usually close. In cases where a fistula has 
long continued to discharge urine or pus, a secondary 
nephrectomy is to be considered. — American Medico- 
Surgical Bulletin, Sept. 12, 1896. 

In the surgical treatment of the kidney, a nephrorr- 
haphy, nephrotomy, nephrolithotomy, pyelolithotomy or 
nephrectomy may be required. The first step in all extra- 
peritoneal operations is a lumbar exploratory incision. 



208 RENAL SURGERY. 

After proper preparation and Ether lias been ad- 
ministered, with the use of Oxygen if necessary, the 
patient is placed on the side opposite to the proposed 
operation and a sand or other pillow placed beneath 
the ilio-costal space of the sound side to increase the 
ilio-costal operating space. The limbs are slightly 
flexed upon themselves, and the body also somewhat 
flexed, the forearms brought in front of the chest and 
the head turned to one side. 

The field of the operation is made aseptic and 
the exposed parts properly protected and covered 
with bi-chloricle cloths. The incision is made directly 
over the posterior surface of the affected kidney; 
it may be vertical, transverse, or a combination 
of both. The vertical incision is made along the 
outer border of the erector spinas muscle (about two 
inches from the spine), extending from the lower edge 
of the twelfth rib to the crest of the ilium. Some- 
times to give more operative space it is necessary 
to continue the incision upwards and sever the lower 
rib. This should not be done if it can be avoid- 
ed, as it sometimes results in pleurisy and other 
complications. If a transverse incision is preferred, 
it should be about three or four inches in length, 
about one inch below and parallel with the free border 
of the ribs. Many make a combination of both in- 
cisions, the transverse being about three inches in 
length so as to give the greatest amount of room for 
the removal of the kidney, if necessary. In these 
operations, the layers of integument, connective tissue, 



RENAL SURGERY. 209 

muscles, etc., are divided, layer after layer, and the 
bleeding points properly secured and ligated and the 
kidney examined by the finger. The operation is com- 
paratively free from danger, although care must be 
taken not to destroy too much of the connective tissue 
which binds the kidney to the posterior wall of the 
abdomen. If no evidence of calculus or disease is 
found, the pails can be properly drained and packed 
with iodoform gauze or the cut edges of the muscular 
layers can be sutured with fine chromicized tendon or 
catgut and the skin closed with fine silk, without 
drainage, the dressing being completed with bi-chloride 
gauze held in place with long strips of adhesive 
plaster, then a layer of cotton and a snug binder. The 
wound will rarely require redressing for seven days. 
Recovery is usually rapid. Many surgeons believe 
that in the majority of cases, good results follow this 
operation, owing to a better fixation of the kidney to 
the abdominal wall, even when no evidence of disease 
is found by the exploratory incision. 

Nephrorrhaphy. — This operation was introduced by 
Halm in 1881. It is almost free from danger, the 
death rate being less than three per cent. The first 
step of the operation is a lumbar exploratory incision. 
The kidney is pressed into and held in place by an 
assistant, by pressure on the front of the abdomen. The 
wound is spread open with retractors, the fatty capsule 
opened and the true kidney capsule exposed. When 
this has been accomplished one of the following 
methods of fixation may be vised : First, sutures are 



2 1 O RENAL SURGERY. 

passed through the adipose capsule alone ; second, through 
the fibrous capsule of the kidney ; third, the sutures in- 
clude a part of the parenchyma of the kidney, about one- 
half inch in width and one-sixth of an inch in thickness ; 
fourth, the fibrous capsule is incised and partly stripped 
off, leaving a raw surface, and the sutures introduced 
through the capsule and parenchyma just inside of 
the border of the raw surface. From four to ten 
sutures are used to attach the kidney to the incised 
wound ; catgut, silk, silk-worm gut or kangaroo tendon 
sutures may be used, according to the judgment of 
the operator. After the sutures are introduced and 
properly tied, the operation may be completed on the 
lines of the closed or open method, and the parts dressed 
antiseptically. In this operation it is necessary that a 
large amount of granulation tissue should be thrown off 
to glue and attach the kidney to its place, and this is best 
fulfilled when the capsule of the kidney is partly 
stripped off. Others advise the suturing of the kidney 
to the twelfth rib, and still others remove a portion of 
the lateral ligament of the spinal column and passing it 
through the kidney parenchyma, anchor the movable 
kidney to its place by a living tissue. The passing of 
the ligament or the sutures through the parenchyma of 
the kidney gives rise to no unpleasant symptoms, except 
possibly a transient hematuria. To make the opera- 
tion successful, no matter which method is used, the 
patient should remain in bed for six or seven weeks, 
to allow the exudate to become thoroughly organized 
and hold the kidney firmly in its place. 



RENAL SURGERY. 2 I I 

Pyeloliihotomy. — It was formerly advised when the 
exploratory incision revealed the presence of a stone 
in the pelvis of the kidney, that an incision should 
be made into the side of the pelvis and the foreign 
body extracted ; but experience has demonstrated that 
while pyelolithotomy was successful, a renal fistula 
usually resulted. They are very troublesome and are 
rarely, if ever, successfully obliterated. Kelly, in the 
Medical News, November 30th, 1895, reports a case of 
pyelolithotomy in which the pelvis of the kidney was 
opened on its posterior wall and a calculus removed. 
The pelvis was united by catgut sutures, the lumbar 
opening closed, and recovery was rapid and perfect. 

Nephrolithotomy. — After the exploratory incision when 
a calculus is discovered in the substance of the kidney 
or its pelvis, either by touch, by the introduction of 
needles or a trocar into the substance of the kidney 
(the trocar being used when fluids are apparently 
present), a nephrolithotomy will be indicated. An as- 
sistant makes pressure on the front of the abdomen 
and pushes back the kidney to its normal position, so 
as to make it more readily recognized. In this operation 
the incision should be made longitudinally along the 
free convex border of the kidney, and of sufficient 
length and depth to allow of the introduction of the 
finger into the calices of the pelvis. If a calculus is 
found it may be removed by the finger or with a pair 
of forceps ; after extracting the calculus the parts must 
be well flushed with a normal saline solution. The 
operation is completed by introducing a drainage tube 



2 I 2 RENAL SURGERY. 

nearly to the openings of the pelvis of the kidney, the 
incision in the parenchyma is drawn together with proper 
sutures, and the external wound closed by silk sutures, 
or the wound packed and dressed antiseptically. In 
operations upon the kidney, hemorrhage is usually 
slight and is easily controlled by packing with iodoform 
gauze. 

Nephrotomy. — In abscess of the kidney or in pyelo- 
nephritis, the pus cavity is opened in the manner described 
above, and proper drainage secured. Many suture the cut 
edges of the kidney to the incision in the lumbar 
region, to facilitate drainage and prevent- the pus from 
burrowing. In large abscesses of the kidney it is 
advisable first to make a nephrotomy for drainage, 
and later, when indicated, a nephrectomy. A ne- 
phrotomy is now considered advisable to relieve the 
tension when the kidney is overcharged with blood, 
as in acute productive nephritis, etc. 

Nephrectomy. — This may be required in certain injuries 
to the kidney, or when degeneration or new growths ren- 
der the kidney useless or a menace to the system in 
general ; occasionally a persistent renal haemophilia, the 
complication of a movable kidney, a calculous kidney, 
or a uretero-abdominal fistula may necessitate the 
operation. Before advising or making a nephrectomy 
the condition of the other kidney should always be 
interrogated. The surface of the kidney is recognized 
through the lumbar exploratory incision and is freed 
from its attachments by the index finger, care being 
taken not to open the peritoneal cavity or rupture 



RENAL SURGERY. 213 

any vessels, whether placed normally or abnormally. 

The kidney, when freed from its attachments with the 
exception of the ureter and its vessels, can be gradually 
and carefully lifted out of its bed and an aneurism 
needle with a stout silk ligature passed under the 
ureteral pedicle. The needle is cut out and the two 
ligatures separated about three-fourths of an inch, 
tied, the pedicle cut between them and the kid- 
ney removed. The ligatured ureteral end is cut 
close and allowed to drop back into the wound ; a 
rubber drainage tube is introduced and the wound 
closed. If the hemorrhage is severe, the vessels may 
be secured by artery forceps, which may be allowed 
to remain for a little time, as they facilitate drainage. 
If the peritoneum is accidentia opened, it must be 
carefully closed with catgut sutures. 

Abdominal nephrectomy. — Is practised, but is not as 
acceptable or advisable as the lumbar operation ; the 
true floating kidney may, however, require this op- 
eration. 

The latest method of removal of the kidney 
by the abbominal route has been suggested and 
its usefulness demonstrated by Dr. Robert Abbe. 
Its advantages are as follows: It allows operation 
in the most advantageous position for the patient 
and operator. It gives about the best access to 
the kidney and ureter. It is the most blood- 
less method, as no muscles are cut. It allows 
of immediate suturing of the separated muscles, secur- 
ing the strongest possible condition of the abdominal 



2 14 RENAL SURGERY. 

wall, precluding subsequent hernia. At a meet- 
ing of the N. Y. Surgical Society, February 24th, 
1897, he presented a kidney removed by his ab- 
dominal route ; the wound healed by primary union, 
and the patient was out of bed on the tenth day. 
The operation is as follows : An incision is made 
from a point one inch inside the anterior superior 
iliac spine and carried upward and backward four and a 
half inches, in a line parallel with the fibres of the 
external oblique muscle. The muscular fibres are 
parted with the index fingers, and an opening 
which admits of all necessary manipulation is readily 
made without dividing any muscular fibres. The 
peritoneum having been reached, the index finger 
is pressed backward to the perirenal fat, the peritoneal 
covering is readily removed from the front of the kidney. 
With good retractors the pedicle can be inspected 
and the ureter separated. In case the operation 
is for a hydro- or pyonephrosis, aspiration will 
empty the fluid and reduce the bulk of the tumor 
before removal. Through the anterior incision the 
finger can follow the ureter to the brim of the pelvis, 
where it can be tied off with a catgut ligature. After 
removal of the kidney, the abdominal wall falls to- 
gether in the lines of muscular separation, and 
three catgut stitches are applied to each. A small 
rubber drainage tube may be inserted for one day if 
there has been extensive stripping of the tissues, but 
this is usually unnecessary. 



CHAPTER XL. 
Symptomatology, etc., etc. 

Acid aceticum. Urine light-colored, greatly increased 
in quantity ; face and limbs have a waxy appear- 
ance. It is especially indicated when the lower 
part of the body and limbs are swollen : anasarca, 
with hot, dry skin, accompanied by gastric dis- 
turbances, sour belching, intense thirst, water-brash 
and diarrhoea. 

Acid benzoicum. Urine smells like horse urine ; 
urine changeable in odor, usually very offensive ; 
high-colored, brownish or black ; urine sometimes 
thick and bloody; specific gravity increased; urine 
hot, excoriating, and may contain mucus and 
pus ; urea diminished in quantity ; uric acid normal ; 
urine cloudy, alkaline in reaction, containing phos- 
phates and carbonates in large quantities ; frequent 
desire to urinate, with tenesmus ; patient pale and 
anaemic ; congestion of the kidney, with increased 
quantity of urine ; dropsy, with the strong, highly 
characteristic odor of the urine which is present im- 
mediately after it is passed. Frequently useful in 
pyelitis. 

Acid carbolicum. Urine scanty, high-colored, green- 
ish or almost black, containing albumen, granular and 
hyaline casts, epithelium and blood corpuscles. When 
administered to animals in toxic doses it has produced 



2l6 SYMPTOMATOLOGY, ETC., ETC. 

the characteristic urine of acute Bright's disease ; 
increase in quantity of urine and frequency in mic- 
turition. Acute nephritis, with uraemia and coma ; 
languor of mind and body, with headache and vertigo, 
and sometimes spinal pain ; sensation as if a tight 
band was stretched around the forehead and temples; 
great fullness of the cerebral vessels ; clonic convul- 
sions ; neuralgic pain, especially over right eye ; fre- 
quent sighing and vomiting. 

Acid gallicum. Is useful in three-grain doses three 
or four times daily for the albuminuria, which continues 
after the oedema and other acute symptoms of acute 
nephritis have disappeared. In this dose it reduces 
the quantity of albumen and increases the flow of 
urine. 

Acid nitricum. Anuria ; urine reddish, scanty, 
offensive, smelling like horse urine ; ammoniacal, con- 
taining blood, pus and mucus ; the urine on standing 
has a whitish sediment ; urine is cold when passed ; 
bloody urine; urging after urinating, with shuddering 
along the spine; albuminuria, with pressing pains in the 
region of the kidneys (5 -drop doses of the first decimal 
dilution three times daily increases the secretion of 
the urine, diminishes the quantity of alb amen voided, 
and reduces the dropsy) ; urine pale, specific gravity 
low, acid in reaction; frequently indicated in gran- 
ular degeneration of the kidney, with gastric dis- 
turbances and general symptoms of atonic gout, etc., 
beneficial in amyloid or waxy nephritis, with the 
general symptons which accompany it, especially when 



SYMPTOMATOLOGY, ETC., ETC. 2 I 7 

of specific origin; great weakness sometimes noticed 
earlv in the morning is a very characteristic indica- 
tion for this remedy in the more chronic urinary dis- 
eases ; pain of a pressing character in the lumbar 
region ; contractive pain from the kidney towards the 
bladder ; it may be indicated in pyelitis. 

Acid plwsplioricum. Urine milky, mixed with jelly- 
like and bloody particles ; pale and copious, containing 
excess of phosphates, alkaline in reaction ; accom- 
panied by pain in the back and general nutritive dis- 
turbances ; on standing the urine becomes dark and 
turbid, and rapidly undergoes decomposition ; albumin- 
ous urine ; it is useful in amyloid and waxy nephritis, 
and is well indicated by the hectic and other 
evidences of suppuration elsewhere in the body 
that precede and accompany it ; also useful in 
reducing the quantity of albumen secreted after the 
subsidence of an acute attack of nephritis. The men- 
tal condition of complete indifference is characteristic. 

Acid picricum. Urine dark yelkrvv, red, brown, with 
strong odor ; specific gravity increased ; urates abun- 
dant ; indican abundant ; granular casts ; fatty de- 
generation of the renal epithelium ; it is useful in 
intermittent hematuria, with degenerated blood cor- 
puscles, the coloring matter being liberated and allowed 
to stain the urine ; also for sub-acute and chronic 
nephritis, with anasarca and dark, bloody urine ; sore- 
ness over the kidneys, worse on the right side ; 
extreme weakness. 

Aconite. Urine scanty, afterwards copious ; albu- 



218 

urinous, sometimes bloody, containing casts ; sup- 
pressed, dark, red and hot ; acid in reaction. 
Congestion and inflammation of the entire urin- 
ary tract ; congestion or acute nephritis from cold, 
with rapid development of general anasarca ; high 
fever and restlessness, with pain referred to the region 
of the kidneys; sensitiveness of the kidney region; 
weariness and soreness in the lumbar region ; it has 
been very beneficial in acute nephritis from cold, after 
the desquamation of scarlet fever accompanied by gen- 
eral dropsy ; the child starts from sleep in agony, with 
cold sweat on the forehead and limbs; headache, press- 
ing from within outwards ; throbbing in the forehead 
and temples, aggravated by motion, noise and stooping; 
oppression in the cardiac region, with palpitation and 
great anxiety. 

Adonis vernalis. Is a cardiac tonic increasing the 
contractile power of the heart muscles and causes con- 
traction of the arterioles and possesses diuretic proper- 
ties. The quantity of urine is rapidly increased under 
this actiou and cyanosis gradually disappears. Dys- 
pnoea becomes less marked and respiration more 
regular. Botkin employed it as follows : 

r> Infus. adon. vernal ... 4.0 ad. 200.0 
01. menth. piper .... gtt \\. 
Syr. aurant. cort .... 10.0 
M. 
Sig. Tablespoonful every two hours. 

It is not cumulative in action though it may 

nauseate. Fifteen to twenty drops of the tincture 

may be administered as a dose. 



219 

Annuo); lion carbon tenia. Urine red, as if mixed 
with blood ; turbid, high colored and fetid ; alkaline 
in reaction ; micturition frequent ; it has been found 
very useful in uraemia, when indicated by somnolency 
or drowsiness, with rattling of large bubbles in the 
lungs ; grasping at flocks ; bluish or purplish hue of 
the lips ; brownish color of the tongue ; stupid, non- 
reactive state, etc. 

Apis meUifica. Urine milky, high-colored, even 
black, or dark and frothy ; fetid, bloody, containing 
albumen and casts ; frequent discharge of small 
quantities of urine, which is burning and scalding, 
with pain in the small of the back; vesical tenesmus; 
general anasarca, most marked on the face and head; 
the dropsical conditions develop rapidly ; the oedema- 
tous parts have a waxy, transparent hue, with a 
slightly yellowish cast; in this dropsical condition there 
is no thirst, the eyelids are markedly swollen, and 
the surface of the body feels sore and bruised. It is 
frequently useful in acute nephritis, following scarlet 
fever or pregnancy, and from other causes, with ach- 
ing pains in the back, and soreness on pressure, or 
when stooping ; suppression of urine, oedema of the 
lungs, and inability to lie down, with mental condi- 
tions dulled, etc. ; twitching of the muscles ; tonic 
and clonic spasms ; general lassitude and trembling ; 
faintness and prostration ; rapid pulse ; worse the 
latter part of the night, relieved when sitting erect. 

Apocynum cannabinum. Urine copious, watery, light 
colored and passed almost involuntarily from relaxation 



2 20 SYMPTOMATOLOGY, ETC., ETC. 

of the sphincters ; the prover says that he could hardly 
tell when the urine was passing, and scarcely knew 
when he was through, as it seemed to still want to 
dribble away ; secondary effect, the urine, from inac- 
tivity of the kidneys, becomes scanty and high colored, 
witli dropsy and bewilderment and heaviness of the head, 
drowsiness, disturbed, restless sleep, slow pulse, func- 
tions sluggish, bowels torpid ; oppression in the epi- 
gastrium and chest, can hardly get breath, even to speak ; 
a sinking feeling in the pit of the stomach and bruised 
feeling in the abdomen ; aching in the small of the back 
and general anasarca; great thirst for water, which 
nauseates ; fluttering feeling in the heart, with distress 
in the cardiac region ; pulse irregular, intermittent, 
feeble, then slow. It has been used to relieve all 
dropsical conditions and acts kindly, especially in dropsy 
following scarlet fever; oedema of legs, feet and 
ankles. It is given in substantial doses of one to five 
drops of the tincture, or as "Hunt's decoction." 

Argentum nitricum. Urine dark, containing blood 
and renal epithelium ; urine scanty, concentrated, per- 
centage of inorganic salts increased, with disappear- 
ance of uric acid; sudden urging to urinate, with 
dull aching in the small of the back and over 
the bladder; face rather dark in color and has a 
dried-up appearance ; has been useful in congestion 
of the kidneys and in nephralgia ; urine burns while 
passing and the urethra feels sore ; drowsiness, stupor ; 
convulsions preceded by great restlessness; vertigo, as 
if turning in a circle, accompanied by headache ; 



SYMPTOMATOLOGY, ETC., ETC. 22 1 

head feels painfully full, relieved by being tied up ; 
congestion of the head with throbbing carotids ; 
gloomy; time passes slowly; worries because others 
consume so much time when their acts are in reality ac- 
complished rapidly; impulsive, always in a hurry; 
nervous and easily excited, irritable and anxious. 

Arnica Montana. Urine bloody after injuries to the 
kidneys : urine brown, high-colored or black, of high 
specific gravity, becoming opalescent on boiling and 
clearing on the addition of Nitric acid ; urine loaded 
with phosphates ; bloody urine with red sediment, 
with cutting pains in the region of the kidney ; hema- 
turia ; retention of urine from over-exertion. 

Arsenicum album. Urine burning, high colored, dark, 
scanty or suppressed, containing albumen, with an abun- 
dance of waxy and fatty casts, fat globules, blood and 
renal epithelium ; specific gravity diminished ; urine 
mixed with pus, turbid, greenish, foul smelling, slimy ; 
dark brown sediment ; suppression of urine, with great 
anxiety, restlessness and sinking of the vital forces ; 
uraemia (animals poisoned with Arsenic die comatose 
and post-mortem examination shows the kidneys to be 
congested and enlarged, the epithelial cells charged with 
fatty grannies, and hypertrophy of the left ventricle was 
frequently found) ; urine voided with great difficulty ; 
oedema more or less general, beginning with puffmess 
of the eyes and extremities and terminating in general 
anasarca ; tingling in the fingers, especially of the left 
hand ; dyspnoea, due to cardiac asthma ; the heart may 
beat too strongly, being visible to the friends, or audible 



2 22 SYMPTOMATOLOGY, ETC., ETC. 

to the patients themselves ; aggravated at night and by ly- 
ing on the back ; cardiac palpitation and irregular rhythm 
of the pulse; the heart may be weak and accelerated; 
the dyspnoea may be due to oedema of the lungs, and is 
noticed more when attempting to lie down, in the eve- 
ning, and especially recurs at 12 p. m., and is relieved 
by expectoration ; the dropsical parts have a pale 
waxen look, and blisters appear on the limbs and burst, 
allowing serum to ooze from them ; the skin feels 
cool, while the patient complains of thirst for 
small quantities of water and require it frequently, 
but even this may irritate the stomach and cause 
vomiting. This drug acts well in the nephritis of 
scarlet fever and the chronic nephritis of malarial origin, 
with hypertrophy of the left ventricle of the heart 
and especially in the large fatty kidney ; great anxiety 
is always present with a feeling that it is useless to 
take medicine as they are sure they are about to die ; 
great anguish ; rapid sinking of strength and great 
emaciation ; relieved by warmth ; wants to be wrapped 
up warm. 

Ait rum muriaticum. Urine clear, copious, albumin- 
ous, containing a few casts ; urine increased in quantity 
at first from hyperaemia of the kidneys, finally be- 
coming turbid, resembling buttermilk ; scanty and 
albuminous, with frequent micturition; worse at night; 
pressing pains or feeling of heat around the waist 
extending to the bladder or down the sides, accom- 
panied by despondency ; suicidal tendency. It has 
been used successfully in the dropsy of pregnancy and 



SYMPTOMATOLOGY, ETC., ETC. 223 

chronic Bright's from syphilis; it rarely does any good 
unless the condition is secondary to cardiac or hepatic 
disease, with nervous symptoms hypochondriasis, over- 
sensitiveness to pain, irritability, and vertigo. In inter- 
stitial nephritis it diminishes the quantity of albumen. 

Belladonna. Urine scanty, deep red, turbid like 
yeast, albuminous, with reddish or thick white sedi- 
ment, micturition difficult, voided by drops ; congestion 
or acute inflammation of the kidneys with flushed 
face and feverish condition, possibly delirium, with 
tendency to strike and bite. The least jar of the 
patient increases the pain, etc. It relieves the con- 
gestion of the malpighian capillaries, but does not 
have any effect upon the secreting epithelium of the 
convoluted tubes ; large doses aggravate, while smaller 
doses rapidly relieve the renal hyperemia. 

Berber is vulgaris. Urine yellow, red with a reddish 
and bran-like sediment, frothy; blood- red urine; green- 
ish urine, or pale yellow w r ith slight, transparent, gela- 
tinous sediment which does not deposit ; or a turbid, 
flocculent, clay-colored, copious mucous sediment, 
mixed with white or whitish-gray, and later a reddish, 
mealy sediment ; sticking, digging, tearing pains 
in the region of the kidneys, wwse from pressure ; 
tearing, pains extending from the back down the 
ureters into the pelvis ; in fact, in all directions to 
the pelvis, hips and loins, labia and testicles, etc.; 
tensive, pressing pains across the small of the 
back ; back feels stiff and numb ; a bubbling feel- 
ing as if water was coming up through the skin. 



224 

Violent stitching, tearing, burning pain in the region 
of the kidneys, extending forward along the course 
of the ureters into the bladder, to the posterior part 
of the pelvis and thighs ; worse when stooping, lying 
or sitting, relieved by standing; stitches from the 
kidney to the bladder with frequent desire to 
urinate ; drawing, tensive, tearing pains in the lum- 
bar region ; violent stitches in the bladder with 
frequent micturition ; cutting, constrictive pain in blad- 
der, whether full or empty ; desire to urinate, with 
burning in urethra ; burning in the urethra after 
micturition ; motion aggravates the urinary troubles ; 
pain in the loins and hips generally accompanying 
the symptoms ; vesical irritability ; burning, cutting and 
sticking pain in the urethra ; frequent micturition, 
with burning before and during the act, especially 
in the female. This remedy has been of marked 
benefit in renal colic, gravel, and pyelitis, with great 
general prostration, and the face often gives evidence 
of deep distress or disease. 

Caffeine. Is a diuretic and heart tonic ; acts well 
in chronic croupous nephritis, with dilated heart 
and mitral or aortic disease ; with general anasarca 
and ascites, 3 grain doses, three times a day ; it 
acts more prompt than Digitalis, and is not cumu- 
lative in action ; five grains has been known to 
cause cardiac distress, though 8 to 80 grains are 
frequently given daily. 

Calcarea carbon ica. Offensive, dark urine, contain- 
ing thick mucus and depositing a white sediment 



SYMPTOMATOLOGY, ETC., ETC. 225 

like flour ; involuntary discharge of mine when walk- 
ing; frequent micturition at night; nocturnal enur- 
esis, urine clear and sour-smelling. Prof. Lillienthal 
considered this remedy in the 30^ potency the most 
frequently indicated and the most useful remedy in 
renal colic. It is especially indicated in stout, flabby 
and light-complexioned patients and in ailments aris- 
ing from living in damp houses or places. 

Camphor. Urine scanty, red or dark yellow, some- 
times green ; strangury ; renal congestion has some- 
times been relieved by this remedy ; coldness of 
the body, yet the patient throws off the clothing, 
and will not remain covered. 

Cannabis Inclica. Urine copious, clear and light col- 
ored or colorless ; at times scanty, dark and red, with 
burning and biting on micturition ; it has given good 
results in uraemia with severe headache and sensation 
as if the vertex was opening and closing ; for- 
getful ; forget what they intended to say ; conflicting 
thoughts, associated with delusion of time and space ; 
they tell you they have had nothing to eat in months 
when the empty dishes are before them ; objects 
a few feet distant seem a long distance off; all sen- 
sations and emotions (be they pleasant or painful) are 
exaggerated. These mental indications frequently lead 
us to the use of this remedy in chronic nephritis, 
with very gratifying results. 

Cannabis sativa. Urine scanty, red and turbid, with 
drawing pains in the region of the kidneys extending 
to inguinal region, with anxious sensation at the 



2 26 SYMPTOMATOLOGY, ETC., ETC. 

epigastrium ; useful in Bright's disease accompanying 
or the sequela of urethritis or cystitis. 

Cantharides. The specific gravity of the urine is 
always high, it is acid in reaction, and contains large 
quantities . of urates ; urine red, dark, scalding and 
scanty ; contains blood and pus corpuscles, epithelium 
and casts from the tubuli uriniferi ; hematuria, urine 
red, as if mixed with blood, turbid, albuminous ; 
micturition frequent and exceedingly painful, especially 
after the act. It acts on the secreting parts or 
tubes of the kidney tissue, and is useful in suppres- 
sion of the urine in nephritis following scarlet fever, 
and other acute forms from cold, exposure, etc. ; 
ursemic symptoms, stupor and mental torpor, with 
high fever, hard, frequent pulse, pain in lumbar region, 
and drawing, tearing pains in the region of the kidney, 
which is sensitive to the slighest touch, with tenes- 
mus of the bladder ; pains in the kidneys, loins and 
abdomen, with constant desire to urinate ; burning, sting- 
ing and tearing in the region of the kidneys ; violent 
pressing pain in the lumbar region, extending to the 
bladder ; the cystitis calling for Cantharis is of a high 
inflammatory grade with hematuria ; it may be ac- 
companied by a chill, fever, etc.; in the gravel of 
children the pains extend down the penis, and there is a 
constant inclination to pull at the organ ; thirst, but 
drinking always increases the pains in the bladder. The 
drug is useful also as a diuretic in chronic Bright's dis- 
ease, relieving the cephalalgia, mental symptoms, coma, 



SYMPTOMATOLOGY, ETC., ETC. 22; 

etc.; it may be useful for the convulsions and fre- 
quently prevents their appearance. 

Ca/rbo vegetabilis. Urine has a strong odor, is dark- 
colored, as if mixed with blood, and deposits a sedi- 
ment. 

Causticwm. Urine light colored, with flocculent 
sediment ; lithiates ; urine loaded with urates from 
disease or exhaustion, without other marked symp- 
toms ; azotnria, with depression of spirits, debility, 
sour perspiration and excessive tissue waste. 

Chelidonium majus. Urine dark yellow, turbid 
when passed ; dark red or brown like beer, tinged 
with bile, and containing an excess of phosphates 
and uric acid, tube casts and epithelial cells, with 
diminution of the chlorides ; oedema of the ex- 
tremities. Croupous nephritis has been cured with 
this remedy ; it is especially useful in the nephritis 
accompanying pneumonia in children. Pain in right 
kidney and liver; pains from the kidneys towards 
the bladder, followed by evacuation of turbid urine; 
drawing, tearing pains in the back, as if broken, 
aggravated by motion. 

Chininum sidpliuricum. Gravel; urine is scanty, 
acid, turbid, of strong odor, and flows slowly, with 
a sediment of yellowish-red crystals, or clear, con- 
taining four-sided prisms, the pointed ends being 
enveloped in mucus ; urine turbid, alkaline, choco- 
late-colored, with increase of phosphates ; sediments 
yellowish-white, mealy, like brick-dust, or in slimy 
flakes, with large numbers of transparent, colorless 



2 28 SYMPTOMATOLOGY, ETC., ETC. 

and orange-colored crystals; star-like, rhomboidal and 
flat crystals, mostly phosphates ; cramping and neural- 
gic pains in the region of the kidneys. 

Chloral um liydrahun. Has been used extensively 
in uremic convulsions in ten to thirty grain doses 
in rectal suppositories or injections. 

Cina. Urine turbid and increased in quantity, urea 
augmented ; urine has an orange or bloody tint ; hema- 
turia in children ; bruised feeling in small of the 
back, not increased by motion ; a feeling of con- 
striction around the loins. 

Coccus cacti. Renal colic ; chronic cystitis ; draw- 
ing, lancinating pain in the lumbar region, extend- 
ing along the course of the ureters ; cutting pain and 
heaviness in the bladder with constant urging to 
urinate, relieved by micturition ; frequent ineffectual 
attempts to urinate at night, has to wait a long 
time before he can succeed ; retention of urine 
until there is intense pain, when a small amount 
is passed slowly, with much suffering; pain and 
soreness in the region of the bladder; hematuria. 

ColcMciim. Urine dark, turbid or bloody, black 
as ink, albuminous, scanty or dark brown, with 
frequent urging to urinate ; dropsy in gouty patients, 
with nervous weakness and hypersensitiveness ; over- 
sensitiveness to touch ; senses too acute, affected by 
strong odors ; gastric symptoms prominent ; mental 
labor fatigues ; inability to fix thoughts or think con- 
nectedly ; headache ; sleepiness during the day, wakeful 
at night; awakes with frightful dreams; the scalp feels 



SYMPTOMATOLOGY, ETC., ETC. 229 

tense ; tongue coated, nausea, great muscular weakness, 
copious salivation and increased urinary secretion ; ne- 
phritis, with severe drawing, stitching, tensive pain in 
the region of the kidneys, aggravated by stretching out 
the legs, by pressure over the kidneys, relieved by 
lying on the back and drawing up the legs ; pain in the 
back and sacrum; constant chilliness, with cold ex- 
tremities ; coldness in the stomach ; dropsy, with sup- 
pression of urine, especially in Bright's disease, with 
hydrothorax. Ruddock especially recommends this 
remedy in cirrhosis of the kidney, due to lead poisoning 
and in the gouty, with developing amaurosis. 

Convallaria majalis. Urine scanty and albuminous ; 
frequent micturition, the urine is burning and hot; 
lame feeling in the back, aggravated by lying down; 
it has been useful in the dropsies of chronic croupous 
and interstitial nephritis, and in the nephritis fol- 
lowing scarlet fever ; cardiac hypertrophy and valv- 
ular lesions ; cardiac irregularity. 

Copaiva. Urine bloody and albuminous, with strang- 
ury; urine copious, burning and scalding when passed; 
large doses cause renal congestion, and consequently 
scanty urine. It has cured desquamative nephritis 
with ascites and general anasarca, as well as the ne- 
phritis following scarlet fever. 

Cuprum aceticum. Urine dark red; complete sup- 
pression ; albuminuria ; ursemic vomiting, stupor, con- 
vulsions, with blueness of the face and lips, eyeballs 
rotated inwards, frothing at the mouth, with violent 
convulsions ; extensor muscles most prominently af- 



23O SYMPTOMATOLOGY, ETC., ETC. 

fected; convulsions, followed by deep sleep; dyspnoea, 
delirium, awakening with fright ; uraemia, resulting 
from fatty degeneration of the kidneys. Convulsions 
begin in the fingers and toes and spread over the 
body ; great restlessness between the attacks ; de- 
cided metallic taste in the mouth. 

Digitalis purpurea. Urine dark red, blackish, turbid, 
scanty, albuminous and of high specific gravity ; 
it may be suppressed or copious with constant urging 
to urinate and inability to retain it (the urine, how- 
ever, is more easily retained in the recumbent po- 
sition); specific gravity diminished; it is useful 
when the dropsy is due to or associated with cardiac 
weakness ; it is indicated in anasarca, with bluish 
cast of the oedematous portion of the body ; a very 
frequent symptom is infiltration of the scrotum and 
penis ; suffocative spells with sensation of contraction 
of the chest, as if it was grown together ; passive 
hyperaemia of the kidneys ; pulse feeble and slow, 
greatly accelerated on standing (hydropericardium) ; 
dropsy, with scanty, turbid, albuminous urine ; sink- 
ing and faint feeling at the pit of the stomach ; 
in large doses it is a diuretic, but the increased 
secretion of urine favors the retention of urea; in 
acute nephritis it is used as a diuretic, but it acts 
best in passive renal congestion due to enfeebled mus- 
cular power of the left ventricle and deficient action of 
the tricuspid valve, with scanty urine, oedema of the 
lungs and dropsy; Digitalis is not a renal irritant; it is 
frequently prescribed as follows : 






SYMPTOMATOLOGY, ETC., ETC. 23 I 

R Tinct. digitalis ? sa- 

Acetum scillae 5 T §^- 

Spiritna etheris nitric I rr- 

M. 

Sig. Teaspoonful every three or four hours. 

Or digitaline one-fourtli to one-lialf a milligramme in 
divided doses in twenty-four hours, or four drops oi 
the tincture from the fresh plant every three or four 
hours ; sometimes teaspoonful to tablespoonful doses of 
the infusion made from the English leaves, repeated 
every four hours, quickly reduce dropsical accumula- 
tions, by increasing the systolic contraction of the 
heart. 

Dulcamara. Urine scanty, bloody, albuminous ; ne- 
phritis resulting from cold and wet ; acute croupous 
nephritis, with drawing pains in the small of the back, 
and chronic nephritis from the same cause with copious 
discharge of urine ; turbid and offensive ; great lassi- 
tude ; a feeling of fatigue compelling one to sit or 
lie down. 

JEquisetum liyemale. Urine scanty, high-colored, al- 
buminous, bloody. 

JEuonymin. Urine albuminous, with depression of 
spirits; headache, pain in the head and back, convul- 
sions, thickly-coated tongue, dyspepsia, nausea ; es- 
pecially useful when associated with derangements of 
the liver and general anaemia. 

JEupatormm perfoliatum. Nephritis of malarial origin, 
especially when associated with the characteristic 
chill, fever, and great pain in the bones. 

Ferritin mtiriaticum. Urine copious, reddish; specific 



232 SYMPTOMATOLOGY, ETC., ETC. 

gravity varying from 1005 to 1025 ; loaded with 
blood corpuscles ; copious, with whitish sediment ; 
copious, with prostration and nervousness ; con- 
stant urging to urinate, with pain in the chest, 
liver, and region of the kidneys ; pain in lumbar 
region, relieved by walking, worse after sitting; 
chronic Bright's disease ; fatty degeneration of the 
kidneys ; albuminuria. It is indicated in proportion as 
the hepatic, digestive and assimulative functions are 
normal, and the elimination of albumen is in- 
independent of recent congestion or inflammation; 
it is beneficial in the enfeebled action of the 
heart, especially in chronic or sub-acute interstitial 
nephritis ; it reduces the amount of albumen, epi- 
thelium, etc. It is indicated in those who are much 
debilitated, especially when the face is pale and 
flushes easily. 

Ferrum phospliorimm. Urine pale and copious. It 
is useful in chronic Bright's disease, diminishing the 
secretion of albumen. 

Formica rufa. Urine albuminous and bloody, with 
much urging to urinate. 

Glonoinum. Urine copious, albuminous and high- 
colored; polyuria, with very low specific gravity, 
great arterial tension, and violent action of the 
heart ; it has acted kindly in puerperal convulsions 
occurring during labor ; face bright red and puffy, pulse 
full and hard, frothing at the mouth, patient un- 
conscious, hands clenched, with thumbs in the 
palms ; cerebral hyperemia, pain in head, aggravated 



SYMPTOMATOLOGY, ETC., ETC. 233 

by shaking the head or moving the body, relieved 
by external pressure; sensation of tension, throb- 
bing, etc., in the heart. It acts kindly in ursemic 
dyspnoea. 

Graphites. Urine ill-smelling, dense, deposits a thick 
white sediment ; urine covered with an irridescent 
film, or has a sour odor ; pain in the sacrum and 
coccyx on urinating. 

Hamamelis Virginica. Urine bloody ; back feels as 
though it would break. 

Helleborus niger. Urine dark, scanty and smoky ; 
containing blood, depositing on standing a sediment 
looking like coffee grounds ; congestion of the kidneys 
with frequent urging to urinate with anasarca and 
ascites ; dropsy following scarlet fever ; suppression 
of the urine ; torpor predominates ; blunting of the 
general sensibilities ; eyes do not re-act to light, or 
while the patient sees imperfectly he does not regard 
the objects seen, hardly remembers what he sees 
or hears ; takes no pleasure in anything ; cor- 
rugation of the muscles of the forehead; slow 
pulse with rapidly developing dropsies ; giddiness, 
stupor or excitement and restlessness ; pupils dilated 
and squinting; pain in the head so violent that there 
is constant change of position ; headache referred to 
the occipital region ; dull pain, worse on stooping, 
extending from the neck to the vertex; stiffness and 
contractive pains in loins as if beaten; face swollen 
and puffy ; nausea and vomiting ; absence of thirst ; 
convulsions with cold extremities. This remedy acts 



234 SYMPTOMATOLOGY, ETC., ETC. 

best in five-drop doses of the tincture in acute nephritis 
with sudden dropsies ; urine scanty and albuminous ; 
it is frequently called for in nephritis following scarlet 
fever. The secondary effect of Helleborus is an in- 
creased secretion of urine, which is voided without urging. 

Helonias dioica. Urine copious, finally becoming 
scanty, light-colored, urea increased, specific gravity 
lowered ; pain over the kidney region, with suppression 
of the menses, congestion of the kidneys, and al- 
buminuria; phosphates increased; urine turbid and 
scanty, frequent micturition, with weakness and great 
restlessness ; stupid, depression of spirits, loss of ap- 
petite, easily fatigued, debility, emaciation, tired feel- 
ing ; nephritis of pregnancy ; pain and weight, with 
a sensation of burning in the region of the kidneys. 
All symptoms are relieved by motion. 

Hepar sidphuris calc. Urine dark-red, hot, be- 
comes thick, turbid, and deposits a white sediment 
on standing. It has been especially useful in post- 
scarlatinal nephritis, where there is a large quantity 
of mucus and epithelia deposited in the urine. 

Hydrangea arborescens is a valuable and important 
remedy for renal colic, gravel, and as a uric acid 
solvent. In a large number of cases where it 
was given for some months without special diet 
there was no return of the trouble. It causes 
the excess of urates and white amorphous salts to 
disappear from the urine. It should be given in 
seven-drop doses of the fluid extract in a little 
water, four times daily. 



SYMPTOMATOLOGY, ETC., ETC. 235 

Hydrocyanicum acidum. Uraemic convulsions; con- 
vulsions, with drawing backward of the head ; res- 
piration irregular and gasping, great distress about 
the heart, fainting spells, with coldness and blueness 
of the surface of the body. 

Ignatia amara. Urine lemon-colored, with white 
sediment ; frequent discharge of watery urine ; pres- 
sure to urinate after drinking coffee. 

Ipecacuanha. Haematuria; hemorrhage from the 
kidneys, attended with nausea and vomiting, with cut- 
ting pains in the renal region, especially after the 
abuse of quinine. 

Kali bichromicum. Urine scanty, reddish, high- 
colored and hot ; suppression of the urine, with pain 
in the region of the kidneys. In animals poisoned 
with this drug the kidneys are found greatly congested, 
and the tubular portion softened and undistinguish- 
able from the rest of the kidney tissue ; the urine 
is purulent, or suppressed. 

Kali carbonicum. Urine dark and turbid, loaded 
with urates ; weak, lame feeling in the small of the 
back, with great exhaustion of the muscular system ; 
aggravation of all symptoms from 3 to 4 a. m., and 
from cold. 

Kali cliloricum. Urine bloody, scanty, albuminous ; 
acute nephritis. 

Kali liydroiodiciim. Urine dark and scanty, with a 
dirty yellowish sediment, or copious and clear ; urea 
diminished ; thirst, with heat in the head ; useful in 
sub-acute and chronic nephritis of specific origin with 



236 SYMPTOMATOLOGY, ETC., ETC. 

darting pains in the region of the kidneys ; feeling as 
if the small of the back was being squeezed in a vise ; 
burning pain in the lumbar region, with difficulty in 
walking. 

Kalmia latifolia. Urine yellow and copious, or 
diminished in quantity, feeling hot when voided; mic- 
turition frequent ; pain in renal region, worse at night ; 
pain in the cardiac region and excessive palpitation. Is 
especially useful in the sub-acute nephritis of preg- 
nancy. 

Lachesis. Urine dark, almost black, albuminous ; 
the respiratory symptoms and all other conditions are 
worse after sleep ; the blue condition of the cedema- 
tous surfaces are characteristic ; dyspnoea on awaken- 
ing, inability to lie down ; drawing pains in the back 
extending to the hips or up the back. This remedy 
may be called for in the nephritis of scarlet fever and 
diphtheria. 

Lithium carbonicum. Urine red, scanty, turbid, 
with reddish-brown sediment ; albuminuria, with frequent 
urination, accompanied by great debility and especially 
an over-acid condition of the stomach. 

Lycopodium clavatum. Urine turbid, with red sandy 
deposits ; lithaemia, colic with pain on the right side, 
urine dark and burning; urine of strong odor, sup- 
pressed, sometimes copious ; calculus with bloody 
urine ; urine profuse, dark, bloody, with much red 
sandy sediment ; greasy coating on the surface of the 
urine ; red sand on child's diaper ; before micturition 
the child screams with pain ; urine turbid, milky, 



SYMPTOMATOLOGY, ETC., ETC. 237 

with a thick purulent sediment and offensive odor; 
pressing pain in perineum during and after mictu- 
rition ; urging to urinate, must wait some time before 
he can void it; frequent desire to urinate with scanty 
flow ; terrific pain in the back before urination, re- 
lieved as soon as the flow begins ; smarting and 
burning when urinating ; drawing, cutting pain through 
to the abdomen ; pain in the kidney and blad- 
der with frequent urination ; renal colic from the pass- 
age of small calculi, the pain is burning and cutting 
in character ; useful in chronic Bright' s disease with 
anasarca and the characteristic digestive disturbances ; 
dropsies of the lower half of the body ; the upper 
pari, arms and chest emaciated; abdomen and leg 
swollen, cedematous, covered with ulcers from which 
serum oozes ; all symptoms worse from 4 to 8 P. m. 

Mercurhis corrosivus. Urine copious, afterwards 
thick, scanty, bloody, and acid in reaction ; it has 
caused complete suppression; urine albuminous, con- 
taining granular and fatty casts with epithelia from 
the tubuli uriniferi ; the general firmness of the tissue 
of the body disappears ; skin earthy, pale ; eyelids and 
ankles cedematous ; loss of appetite, quick and fre- 
quent pulse, great weakness and prostration, dispo- 
sition to perspire on the slightest exertion, lassitude 
and soreness, great restlessness in the limbs, must 
change position constantly ; sleepiness during the 
day, but not relieved by long sleep ; sleep at night 
disturbed, awaking with dreams which terrify ; dullness 
in the forehead ; aching and weariness in the back 



238 SYMPTOMATOLOGY, ETC., ETC. 

of head and neck ; sensation as if a band was tied around 
the head ; qualmishness, weakness and tenderness in 
the epigastric region ; nephritis complicating pregnancy : 
suppurative nephritis; inflammation of the kidneys, 
with scanty albuminous urine, frequent urination and 
pain in the back ; in acute nephritis, the albumen, 
blood and oedema rapidly disappear under this remedy. 

Mercurius clulcis. Is often required in interstitial 
nephritis. 

Nux vomica. Urine pale, containing thick, white 
mucus or purulent matter ; dark urine, depositing a 
red brick-dust sediment ; bloody urine ; nephritis, 
accompanied by digestive disturbances ; vomiting, 
of renal origin : nausea after eating ; thirst, poly- 
uria; patient irritable, sullen, with desire to be alone, 
and to recline and keep quiet, etc. 

Ocimum canum. Urine red, with brick-dust sedi- 
ment and blood ; saffron-colored urine ; turbid urine, 
depositing a white albuminous sediment ; burning 
during micturition ; pain in ureters, and deposit in 
urine of a large quantity of red sand ; renal colic ; 
gravel ; cramping pain in the kidneys, especially in the 
right ; renal colic, with micturition every fifteen 
minutes, the pain causes the patient to wring his 
hands, moan and cry. 

Opium. Urine red, scanty and cloudy, or lemon- 
colored, with a reddish sediment ; indicated in uraemic 
coma from contracted kidneys ; morphia, in % to 1 
grain doses hypodermically, has been successfully 
used in ursemic convulsions. 



SYMPTOMATOLOGY, ETC., ETC. 239 

Petroleum. Urine dark yellow, bloody and turbid, 
containing brown clouds after standing ; odor offensive, 
sour, ammoniacal ; urine suppressed during the day, 
copious at night ; urine albuminous, containing granular 
and hyaline casts ; urine has a reddish sediment, and 
is covered with a glistening film ; useful in chronic 
nephritis with gastric symptoms and dropsy, also in 
renal hemorrhage, with pain in the renal region ; 
chilliness, frequent micturition, and oedema of the 
lower extremities. 

Phosphorus. Urine thick, turbid and scanty, con- 
taining blood corpuscles and albumen ; urine brown, 
with red sandy deposit ; urine bloody ; it may be 
pale, watery, or whitish like curdled milk, containing 
fatty and waxy casts, pus and blood corpuscles ; 
specific gravity diminished ; acute pain in the re- 
gion of the kidneys and liver, with jaundice ; urine 
covered with an irridescent fatty matter ; especially 
useful in fatty and amyloid degeneration of the kid- 
neys when associated with similar pathological condi- 
tions of the liver and the right heart ; venous stasis ; 
oedema of the lungs ; weakness of memory ; difficulty 
in concentrating the mind ; vertigo ; confusion in head ; 
weak, empty feeling in the whole abdomen ; especially 
indicated in tall, slender individuals. 

Phytolacca. Urine dark red, mahogany colored, with 
painful micturition ; pain and soreness in right renal 
region; has been beneficial in chronic nephritis. 

Piclri. Urine bloody, epithelial, granular or waxy 
casts; acute nephritis. 



24O SYMPTOMATOLOGY, ETC., ETC. 

Pilocarpin muriaticum. One-fourth to one-third grain 
doses of the hydro-chlorate hypodermically three times 
a day has been followed by profuse sweating and 
lowering of the temperature. In a case reported of 
convulsions in puerperal nephritis with complete anuria 
and face and body highly oedematous, the convulsions 
ceased with the re-establishment of the urinary secre- 
tion, and recovery followed. 

Plumbum metallicum. Urine scanty and dark; albu- 
minous, not accompanied by general oedema; urine 
brownish-red, turbid, sediment containing blood cor- 
puscles, casts and albumen in abundance; has been useful 
in acute nephritis with mental depression and bloody 
urine, but is especially indicated in chronic granular 
gouty or cirrhotic kidneys with amaurosis, depression 
of spirits, cachexia, numbness of the lower extremities 
and dropsy. It has been found to diminish the quan- 
tity of albumen ; uric acid is diminished ; cerebral 
symptoms ; clonic spasms of the face and limbs, slight 
dropsy, little albumen, with a marked tendency to 
uraemic convulsions ; small granular contracted kid- 
ney and albuminuria is found in a large percentage of 
patients with lead poisoning ; in chronic lead poisoning 
it causes interstitial nephritis, atrophy of the kidney, 
adhesion of the capsule, and the formation of small 
cysts in the substance of the kidney ; the tubule 
uriniferi are first affected, with proliferation of the 
epithelia and formation of casts ; it involves both the 
cortical and medullary portions of the kidney, but some 
parts are usually more affected than others, and many 



241 

symptoms similar to gout are developed while the 
chronic poisoning is going on. 

Pulsatilla. Urine bloody, reddish ; mucous, jelly-like, 
slimy deposit which sticks to the chamber ; brick-dust 
sediment ; suppression of the urine with the general 
symptoms of this remedy ; spasmodic pain at the neck 
of the bladder extending to the pelvis and thighs ; 
frequent and almost ineffectual urging to urinate ; in- 
voluntary urination at night in bed ; constant pressure 
in the bladder with frequent desire to urinate ; the 
urine is discharged while walking or standing. 

Rhus toxicodendron. Urine dark, turbid and scanty ; 
lias been useful in acute nephritis with cutting pains 
in the back, general ceclema resulting from exposure 
to wet; great oedema of the legs, with ulcers exuding 
serum. 

Sabi na. Urine red and scanty, bloody, albuminous; 
strangury ; dragging pains in the back extending to 
the pelvic region and thighs in rheumatic and arth- 
ritic subjects. 

Sandal wood. Urine albuminous, associated with 
great pain in the lumbar region ; acute nephritis. 

Sarsaparilla. Urine copious, clear, scanty and 
slimy; clay-colored and scanty; sand in the urine 
or on the diaper; child screams before and during 
micturition: the urine contains pus, blood and mucus; 
fiery red, turbid urine containing long flakes; urine 
excoriating; pain in the lumbar region going forward; 
abdomen distended; severe tenesmus; painful con- 
striction of the bladder; micturition frequent and in- 



242 SYMPTOMATOLOGY, ETC., ETC. 

effectual, ending by passing blood ; chills run from the 
bladder to the back ; gravel passes after urinating ; 
has to get up in the night frequently to urinate ; re- 
tention of urine. 

Secale cornutum. Urine has a cheesy sediment ; 
has been used in post-scarlatinal nephritis. 

Senecio aureus. Urine scanty and bloody ; inflamma- 
tion of the kidneys with renal dropsy and pain in 
the kidney region resulting from or following the 
passage of a urinary calculus ; sometimes useful in 
oedema of the lungs accompanying croupous nephritis ; 
dyspnoea on ascending the stairs. 

Senna. Excess of urea, chloride of sodium and 
phosphates in the urine. 

Sepia. Urine thick, slimy, offensive, depositing a 
yellowish, pasty sediment ; urine turbid, clay-colored ; 
urine turbid and dark when passed, as if mixed with 
mucus ; on standing it deposits a white or reddish 
sediment and becomes offensive ; deposit of brick-dust 
sediment, uric acid, bile pigment, blood, etc. ; fetid 
urine, with reddish, clay-colored sediment adhering 
to the chamber ; the urine is so offensive that it must 
be removed at once ; the discharge of mucus in the 
urine does not take place every time the urine is 
passed, but occurs periodically; urine dark, turbid, and 
mixed with pus ; thick, slimy, turbid and offensive, 
depositing a pasty sediment; the lower part of the 
abdomen feels distended, with tension and soreness ; 
frequent, painful, and ineffectual urging to urinate, 
until long effort and waiting have about tired out the 



SYMPTOMATOLOGY, ETC., ETC. 243 

sufferer; desire to urinate, with bearing down in the 
pelvis; burning and cutting when urinating; chill and 
beat in the head during and after micturition ; pulsation 
in the small of the hack ; sprained pain over the hips ; 
pain in the lumbar region ; deep-seated pressive pain 
and tension in the lumbar region; gravel; pyelitis. 

Stiff mat a maidis. Retention of urine ; renal colic ; 
gravel ; acute and chronic cystitis ; vesical tenesmus 
and irritation ; pyelitis. 

Stramonium. Suppression of urine, with the char- 
acteristic mental symptoms. 

Sulphur. Urine clear, high - colored or turbid, 
of penetrating odor, with thick deposit, which 
sticks to the chamber ; retention of urine ; urinates 
frequently, with a feeling of obstruction at the neck 
of the bladder and a sense of pressure and disten- 
tion ; bruised sensation in small of back after mic- 
turition ; the pains continue in the urethra until the 
urging to urinate returns ; increased secretion of urine ; 
frequent urination at night ; the desire comes suddenly, 
is imperative, and if not gratified at once micturition 
becomes involuntary; pyelitis; constant urging to urinate 
day and night, in a thin stream or drop by drop. 

Terebinthina. Urine bloody, scanty, smoky, with a 
coffee ground deposit, the sediment consisting of disin- 
tegrated blood corpuscles and casts ; dull, burning 
pains in kidneys, especially from the right kidney 
to the hip ; burning during micturition ; urine dark, 
cloudy, smoky, containing albumen; pressure from 
the bladder to the kidneys, relieved when walking ; 



244 SYMPTOMATOLOGY, ETC., ETC. 

acute or chronic nephritis from cold or malaria. 
It causes active congestion of the capillary of 
the malpighean tufts and glomeruli, exudation of 
blood and albumen, and destruction of the epithelium 
of the tubuli uriniferi; renal hyperaemia and congestion, 
hematuria ; suppression of urine ; uraemia is rare. It 
is often indicated in dropsy after scarlet fever, but more 
frequently when resulting from colds and when con- 
gestion is more marked than the evidence of change 
in the epithelium of the tubules would seem to war- 
rant ; its first effect is to make the urine more copious ; 
dyspnoea, patients must be propped up in bed; 
tongue dry and glossy ; stupor and great weakness. 

Ulex diureticus. This drug produces marked di- 
uresis ; it should not be used with a weak heart or 
when the nephritis is acute ; it increases blood pres- 
sure by irritation of the vaso-motor system ; its ac- 
tion is rapid and transitory ; dose twenty to forty 
drops every three or four hours. 

Uva ursi Urine milky, slimy, yellow, purulent and 
bloody, or red, scanty, high-colored and acid ; pain- 
fulness and soreness in the region of the kidney ; 
uneasy feeling in the left thigh with frequent desire to 
urinate ; the stream is small, and the bladder is emptied 
only with considerable effort ; pain and soreness in the 
left groin; heavy pain in the lumbar region, and un- 
easiness in the bladder; frequently required in pyelitis. 

Zingiber. Suppression of urine ; incessant micturi- 
tion ; strangury ; urine scanty, bloody and albu- 
minous, with other symptoms of acute nephritis. 



I N D K X 



Abscess of the kidney, 201 

embolic infection, 203 

idiopathic, 202 

suppurative pyelonephrosis, 202 

traumatic, 202 

clinical history of, 203 

treatment of, 205 
Absence of the kidney or ureter, 17 
Acid aceticum, 215 

benzoicum, 157, 178, 215 

carbolicum, 38, 215 

gallicum, 216 

hydrocianicum, 38, 235 

muriaticum, 157 

nitricum, 157, 172, 178, 216 

nitro-muriatic, 165, 178 

oxalicum, 165 

phosphoricum, 109, 167, 178, 217 

picricum, 217 

salicylicum, 157 
Aconite, 43, 67, 145, 150, 197, 205, 217 
Adenoma of the kidney, 132 
Adonis vernalis, 218 
Albuminuria, 153 

cause of, 153, 154 
Albuminuria of Piegnancy, 114 

etiology of, 114 

pathological anatomy of, 114 

clinical history of, 115 

treatment of, 116 

surgical, 116 

general, 117 
Amaurosis, 34, 82 
Ammonium carbonate, 38, 67, 219 
Amyloid nephritis, 106 

etiology of, 106 

pathological anatomy of, 106 

clinical history of, 107 

diagnosis of, 108 

prognosis of, 108 

treatment of, 108 
Angioma of the kidney, 132 



Anomalies of the kidney, 17 

" " " pelvis of the kidney, 

19 

" " " renal artery, 18, 19 

" " " ureter, 18 

Anuria, 189 
Aphasia of urajmia, 35 
Apis mellifica, 50, 67, 219 
Apocynum cannabinum, 67, 68, 219 
Argentum nitricum, 183, 220 
Arnica montaua, 43, 45, 197, 205, 221 
Arsenicum album, 38, 50, 52, 67, 68, 

100, 135, 221 
Arsenicum iodatum, 126 
Arterial tension in uraemia, 35 
Arteries, malformation of, 18, 19 
Aurum muriaticum, 100, 222 
Azoturia, 171 



Bacillinum, 126 
Bacteriuria, 56, 67, 68, 155 

etiology of, 155 

pathological anatomy of, 156 

clinical history of, 156 

treatment of, 157 
Belladonna, 43, 50, 145, 150, 197, 205, 

223 
Benzoic acid, 150, 157, 215 
Berberis vulgaris, 150, 165, 183, 223 
Bright's disease, acute, 53 
Bright's disease, chronic, 77 
Bryonia album, 72, 150 
Buchu, 150 



Caffiene, 224 

Calcarea carbonica, 126 

Calcarea hypophosphorica, 126, 224 

Calcarea iodata, 126 

Calcareous calculi, 175 

Calculous pyelitis, 143 



248 



INDEX. 



Calculus of the kidney, 173 

etiology of, 173 

clinical history of, 174 

calcareous carbonate, 175 

cystin, 161, 175 

indigo, 175 

oxaluria, 164, 175 

phosphates, 166, 167. 175 

uric acid, 175 

urostealith, 175 

xanthin, 175 

treatment of, 178 
Camphor, 225 
Cancer of the kidney, 131 
Cannabis Indica, 38, 67, 72, 225 
Cannabis sativa, 150, 225 
Cantharides, 39, 43, 67, 69. 84, 150, 

163, 183, 226 
Carbolic acid, 67 
Carbonate of lime calculi, 175 
Carbo vegetabilis, 227 
Carciuorna of the kidney, 132 
Causticum, 227 

Cavernous growths of the kidney, 130 
Cephalgia in uraemia, 34 
Chelidonium majus, 72, 227 
Chimaphila umbellata, 150 
Chiuinum arsenate, 126 
Chininum sulphuricum, 126, 178, 227 
Chloral um hydratum, 228 
Chyluria, 159 

etiology of, 159 

clinical history of, 159 

treatment of, 160 
Cicuta virosa, 39, 50, 67, 69 
Cina, 228 

Cirrhosis of the kidney, 90 
Coccus cacti, 183, 228 
Colchicum, 72, 228 
Colic renal, 181 
Coma of uraemia, 35 
Contraction of single muscles in uraemia, 

34 
Convallaria majalis, 45, 229 
Convulsions of uraemia, 34 
Copaiba, 229 
Crotalus horrid us, 163 
Croupous nephritis, acute, 53 
Croupous nephritis, chronic, 78 
Cuprum aceticum, 229 



Cuprum arsenite, 39, 67, 69 

Cystic degeneration of the kidneys, 110 

etiology of, 110 

pathological anatomy of. 110 

clinical history of, 112 

treatment of, 113 
Cystin calculi, 161, 175 
Cystin uria, 161 

etiology of, 161 

clinical history of, 161 
Cysts, dermoid, 113 
Cysts, hydatids, 111, 112, 113, 138 

Deith's crisis, 24 

Delirium in uraemia, 35 

Depurative infiltration of the kidney, 

106 
Dermoid cysts of the kidney, 113 
Digestive disturbances in uraemia. 36 
Digitalis, 46, 230 
Dioscorea villosa, 183 
Double kidney, 18 
Dulcamara, 43, 231 
Dyspnoea in Bright's disease. 36 

Eclampsia of pregnancy, 114 
Endotheliomata of the kidney, 130 
Equisetum hyemale, 163, 231 
Erigeron, 135 
Euonymin, 231 
Eupatorium perfoliatum, 231 

Ferrum muriaticum, 85, 135, 231 
Ferrum phosphoricum, 232 
Fibroma of the kidney, 132 
Fistulae of the kidney, 199 

treatment of, 200 
Fistulae of the ureter, 192 

treatment of, 193 
Floating kidney, 20 

etiology of, 20 

clinical history of. 23 

diagnosis of, 27 

treatment of, 29 
Formica rufa, 282 

Gallic acid, 216 
Gelsemium, 29 
Glomerulo nephritis, 78 



INDEX. 



249 



Glonoin, 39, 72, L01, 172, 232 

Gouty kidney, 90 
Graphites, 233 

Gravel. IT? 

Hematuria, 102 

treatment of, 163 
Hemoglobinuria. 162 
Hamamelis Virginica, 135, 233 

Hekla lava, 126, 145, 205 
Helleborus niger, 39, 67. 70. 233 
Helonias dioica, 234 
Hepar sulphuris, 145, 205. 234 
Hydatid cysts of the kidney, 111. 112, 

113* 138 
Hydrangea, 151, 234 
Hydrastinin muriatieuin, 150 
Hydrastinin sulphuricum, 150 
Hydrocyanic acid, 38, 235 
Hydronephrosis, 24, 136 

etiology of, 136 

pathological anatomy of, 137 

clinical history of, 137 

diagnosis of, 138 

treatment of, 139 
Hydruria. 171 
Hyoscyamus. 67 
Hypertrophy of the kidney. 17 

Ignatia, 29, 172, 235 
Indigo calculus, 175 
Injuries of the kidney, 196 

treatment of, 197 
Injuries to the ureter, 192 

treatment of, 193 
lusanity of ureemia, 35 
Interstitial nephritis, chronic, 90 
Ipecacuanha. 135, 163. 235 

Kali bichromatum, 235 

Kali carbonicum, 235 

Kali chloricum, 235 

Kali iodide, 100, 108, 126, 235 

Kali muriaticum, 85 

Kalmia, 236 

Kidneys, absence of, 17, 18, 201 

calculus in, 173, 

oarbonate of lime, 175 

cvstin. 175 



Kidneys, indigo. 175 

oxulates, 175 

phosphates, 175 

uric acid, 175 

urostealith, 175 

xanthin, 175 

congenital absence of, 17, 18 
Kidneys, congestion, acute, of, 41 

etiology of, 41 

pathological anatomy of. 41 

clinical history of. 41 

prognosis of, 43 

treatment of, 43 

congestion, chronic, of, 44 

etiology of, 44 

pathological anatomy of, 44 

clinical history of, 45 

treatment of, 45 

contraction of, 90, 

cystic degeneration of, 110 

etiology of, 110 

pathological anatomy of, 110 

clinical history of, 112 

treatment of, 113 

degeneration, acute, of, 48 

etiology of, 48 

pathological anatomy of, 48 

clinical history of, 49 

treatment of, 50 

degeneration, chronic, of, 51 

etiology of, 51 

pathological anatomy of, 51 

clinical history of, 51 

treatment of, 52 
Kidney, depurative infiltration of, 106 

double lobulated, 18 
Kidney, fistulas of, 199 

treatment of, 200 

floating, 20 
Kidney, granular atrophy of. 90 
Kidney growths, 132 

adenoma of, 132 

angioma of, 132 

carcinoma of, 132 

cavernous of, 130 

endotheliomata of. 130 
fibroma of, 132 
horseshoe formation of, 18 
hydatid of, 112 
hypertrophy of, 17 



5o 



INDEX. 



Kidneys, lipoma of, 132 

lymphadenoma of. 130 

myoma of, 132 

myxolipomatous of, 130 

papilloma of, 132 

sarcoma of, 132 

syphilitic gummata of, 130 

villous of, 130 
Kidney, injuries of, 196 

treatment of, 197 
Kidney, lardaceous, 106 

malformations of, 17 
Kidney, malignant growth of, 131 

movable, 20 

etiology of, 20 

clinical history of, 23 

diagnosis of, 27 

treatment of, 29 
Kidney, suppuration of, 201 

etiology of, 201 

pathological anatomy of, 202 

clinical history of, 203 

treatment of, 205 

supernumary, 17 

surgical, 201 

syphilis, 176 
Kidney, waxy, 106 
Kreosotum, 126 

Lachesis, 29, 163. 236 
Lardaceous nephritis, 106 

etiology of, 106 

pathological anatomy of. 106 

clinical history of, 107 

diagnosis of, 108 

prognosis of, 108 

treatment of, 108 
Lipoma of the kidney, 132 
Lithium benzoicum, 101 
Lithium carbonicum, 101, 236 
Lycopodium, 108, 183, 151, 178, 236 
Lymphadenoma of the kidney, 130 

Magnesia boro-citrate, 151, 178 
Magnesia phosphorica, 178 
Malformations of the kidney, 17 

" " pelvis of the kid- 
ney, 19 
" " renal vessels, 19 
" " ureters, 18 



Malignant growths of the kidney, 131 
Mercurius corrosivus, 43, 67, 70, 85, 

128, 237 
Mercurius dulcis, 101, 238 
Millefolium, 135 
Movable kidney, 20 

etiology of, 20 

clinical history of, 23 

diagnosis of, 27 

treatment of, 29 
Murex purpurea, 172 
Muriatic acid, 157 
Myoma of the kidney, 132 
Myxo lipomatous growth of the kid- 
ney, 130 

Nephrectomy, 212 

abdominal, 213 

lumbar, 212 
Nephritis acute, 47 . 

etiology of, 47 

clinical history of, 47 

prognosis of, 47 

treatment of, 47 
Nephritis amyloid, 106 

etiology of. 106 

pathological anatomy of, 106 

clinical history of, 107 

diagnosis of, 108 

prognosis of, 108 

treatment of, 108 
Nephritis, catarrhal, 90 
Nephritis, croupous, acute, 53 
Nephritis, croupous, chronic, 78 
Nephritis, chronic, desquamative, 78 
Nephritis, exudative, acute, 53 

etiology of, 54 

pathological anatomy of, 56 

clinical history of, 59 

prognosis of, 65 

treatment, medicinal, of, 67 

treatment, general, of, 72 
Nephritis, interstitial, 90 

etiology of, 90 

pathological anatomy of, 93 

clinical history of, 94 

diagnosis of, 99 

prognosis of. 100 

treatment, medicinal, of, 100 

treatment, general, of, 104 



INDEX. 



251 



Nephritis, parenchymatous, acute, ;">:> 
etiology of, 54 

pathological anatomy of, 56 

clinical history of, 59 

prognosis of, 65 

treatment, medicinal, of, 67 

treatment, general, of, 72 

treatment, surgical, of, 75 
Nephritis, parenchymatous, chronic, 78 

etiology of, 78 

pathological anatomy of, 76 

clinical history of, 79 

diagnosis of, 83 

prognosis of, 84 

treatment, medicinal, of, 84 

treatment, general, of, 86 
Nephritis, post- scarlatinal, 53 
Nephritis, productive, acute, 53 

etiology of, 54 

pathological anatomy of, 56 

clinical history of, 59 

prognosis of, 65 

treatment, medicinal, of, 67 

treatment, general, of, 72 

treatment* surgical, of, 75 
Nephritis, productive, with exudation, 

chronic, 78 
Nephritis, red granular, 90 
Nephritis, suppurative, 201 

etiology of, 201 

pathological anatomy of, 202 

idiopathic form, 202 

traumatic form, 202 

suppuratiue pyelonephrosis. 202 

from infectious emboli, 203 

clinical history of, 203 

treatment of, 205 
Nephritis, syphilitic, acute, 128 

etiology of, 128 

pathological anatomy of, 128 

clinical history of, 128 

prognosis of, 128 

treatment of, 128 
Nephritis, syphilitic, chronic, 128 

etiology of, 128 

pathological anatomy of, 129 

clinical history of, 129 

treatment of, 129 
Nephritis, tubal, acute, 53 
Nephritis, tubal, chronic, 78 



Nephroptosis, 20 

etiology of, 20 

clinical history of, 23 

diagnosis of, 27 

treatment of, 29 
Nephrolithotomy, 211, 212 
Nephrorrhaphy, 31, 209 
Nephrotomy, 31, 75, 212 
Nitric acid* 72, 85, 101, 108, 157, 172, 

178, 184, 216 
Nitro-muriatic acid, 178 
Nux vomica, 85, 101, 163, 184, 238 

Ocimum cauum, 238 
Opium, 39, 238 
Oxalicum acidum, 165, 239 
Oxaluria, 164 

etiology of, 164 

clinical history of, 164 

treatment of, 165 
Oxulate culculus, 175 

Papilloma of the kidney, 132 
Pareira brava, 150, 184 
Petroleum, 238 

Phosphate calculus, 166, 167, 175 
Phosphaturia, 166 

functional, 166 

etiology of, 167 

clinical history of, 167 

secondary, 166 

etiology of, 167 

true, 166 

etiology of, 166 

clinical history of, 166 

treatment of, 167 
Phosphoric acid, 109, 167, 171, 178. 

217 
Phosphorus, 46, 52, 85, 178, 239 
Phytolacca, 239 
Pichi, 184, 239 
Picric acid, 217 
Pilocarpin muriaticum, 240 
Plumbum, 67, 72, 101, 240 
Polyuria, 171 

persistent, 171 

transient, 171 

treatment of, 171 
Pulsatilla, 29, 150, 178, 241 



2^2 



INDEX. 



Pyelitis, 142 

etiology of, 142 
acute, primary, 14*2 
chronic, primary, 142 
traumatic, 142 
tubercular, 142 
calculous, 143 
acute, secondary, 143 
chronic, secondary, 143 
pathological anatomy of, 143 
acute, primary, 143 
chronic, primary, 143 
acute, secondary, 144 
chronic, secondary, 144 
clinical history of, 144 
acute, primary, 144 
chronic, primary, 145 
traumatic, 147 
calculous, 147 
tubercular, 147 
acute, seconnary, 148 
chronic, secondary, 149 
prognosis of. 149 
treatment of, 150 

Pyelolithotomy, 211 

Pyelonephritis, 202 
treatment of, 205 

Pyonephrosis, 140 
etiology of, 140 
pathological anatomy of, 140 
clinical history of, 141 
treatment of, 141 

Pyuria, 168 

etiology of, 168 
clinical history of, 160 
treatment of, 170 



Renal anomalies, 17, 20 
" arteries, 18, 19 

Renal calculus, 173 
etiology of, 173 
clinical history of, 174 
treatment of, 178 

Renal cirrhosis, 90 

Renal colic, 181 
etiology of, 181 
clinical history of, 181 
prognosis of, 183 
treatment of, 183 



Renal congestion, acute, 41 

etiology of, 41 

pathological anatomy of. 41 

clinical history of, 41 

prognosis of, 43 

treatment of, 43 
Renal congestion, chronic, 44 

etiology of, 44 

pathological anatomy of. 44 

clinical history of, 45 

treatment of, 45 
Renal crisis. 24 
Renal degeneration, acute, 48 

etiology of, 48 

pathological anatomy of, 48 

clinical history of. 49 

treatment of, 50 
Renal degeneration, chronic, 51 

etiology of, 51 . 

pathological anatomy of, 51 

clinical history, 51 

treatment of, 52 
Renal fistulse, 199 

etiology of, 199 

clinical history of, 199 

reno-bronchial, 200 

reno-cutaneous, 199 

reno-gastric, 199 

reno-intestinal, 199 

treatment of, 200 
Renal iu juries, 196 

treatment of, 197 
Renal sclerosis, 90 
Renal syphilis, 128 
Renal surgery, 206 
Renal tuberculosis, 122 

etiology of, 122 

pathological anatomy of, 123 

clinical history of, 124 

treatment of, 126 
Renal tumors, 130 

etiology of, 131 

pathological anatomy of, 131 

clinical history of, 133 

treatment of, 135 
Reno-bronchial fistulas, 200 
Reno-cutaneous fistulse, 199 
Reno-gastric fistulse, 199 



INDEX. 



2 53 



Reno-intestinal nstnhe, 199 

Rhus tox, 43. 50, 52, 67, 71, 150, 241 

Sabina, 72, 241 

Salicylic acid, 157 

Sandal-wood, 43, 241 

Sarcoma of the kidney, 132 

Sarsaparilla, 178. 241 

Scilla, 72, 171 

Secale, 135, 242 

Senecio. 242 

Senna. 165, 242 

Sepia. 150, 178, 242 

Silicea, 151, 205 

Sodium sulpho-carbolate, 145, 205 

Stigmata maidis, 150, 243 

Stramonium, 67, 243 

Strychnin arsenate, 29 

Syphilis of the kidney, 128, 129 

Sulphur, 29, 150, 178, 243 

Suppuration of the kidney, 201 

Surgical kidney, 201 

Terebinth, 43, 50, 71, 1G3, 243 
Thlaspi bursa pastoris, 163, 184 
Tobacum, 184 
Traumatic pyelitis, 142 
Tubercular pyelitis, 142 
Tuberculosis of the kidney, 122 
etiology of, 122 
pathological anatomy of, 123 
clinical history, 124 
treatment of, 126 
Tumors of the kidney, 130 
etiology of, 131 
pathological anatomy of, 131 
clinical history of, 133 
capsular, 134 
extra-renal, 134 
glandular, 134 
pelvic, 134 
treatment of, 135 

I'lex diureticus. 244 



Uraemia, 32 

etiology of, 32 

clinical history of, 34 

amaurosis in, 34 

aphasia in, 35 

arterial tension in, 35 

contraction of single muscles in, 34 

convulsions in, 34 

delerium and coma in, 35 

digestive disturbances in, 36 

dyspnoea in, 36 

formication in, 37 

headache in, 34 

insanity in, 35 

numbness in, 37 

puritis in, 37 

rheumatism in, 37 

temperative in, 35 

diagnosis of, 37 

prognosis of, 37 

treatment remedial of, 38 
" general of, 39 

Ureteral obstruction, 188 

treatment of, 190 
Ureteral injuries and fistulas 192 

treatment of, 193 
Ureteritis, 186 

etiology of, 186 

clinical history of, 186 

treatment of, 186 
Ureters, malformations of, 18, 
Uric acid calculus, 175 
Urostealith calculus, 175 
Uva ursi, 150, 184, 244 

Veratrum album, 72 

Veratrum viride, 43, 67, 72, 145, 150, 

197, 205 
Villous growths of the kidney, 130 

Xanthin calculus, 175 

Zingiher, 244 



